{"text_format":"1","workbook":"xlsx","n_sheets":7,"sheets":["Intro","Patient Information","Drug Payment Details","Admin Procedure","Dashboard","Calculations","Calc2"],"not_rendered":{"charts":8,"images":5,"macros":1,"external_links":0,"defined_names":5,"comments":0,"pivot_tables":2},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

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[]
[null,"SPINRAZA REIMBURSEMENT TRACKING LOG - GUIDE & INSTRUCTIONS"]
[null," \nTracking health plan reimbursement for SPINRAZA when procured through CuraScript Specialty Distribution (ie, buy-and-bill) is a key for ensuring appropriate patient access and payment. It is important for provider practices to check health plans' explanation of benefits (EOB)/remittance advice (RA) statements for accuracy, in order to detect any claim processing errors or inappropriate adjustments, and to monitor denials. In cases of underpayment or denial, you can follow up with an appeal, as appropriate. Your practice can use the information from your billing system and health plans'  EOBs/RAs to monitor patient access and health plan remittance, and to appeal promptly, if needed. \n\nYou can use the Reimbursement Tracking Log, along with help from your Biogen field representative, to ensure that patients have and maintain clinically appropriate treatment access. This log provides a template for tracking health plan remittance to enable your practice to: \n     – Monitor health plan contract compliance to ensure patients are able to receive access to treatment in a timely manner\n     – Review health plan EOB against contracted fee schedules\n     – Evaluate health plan responsiveness in addressing reimbursement issues\n     – Establish procedure for addressing claim denials and submitting appeals\n\nThis template is designed with 3 spreadsheets to capture the following:\n     1. Patient information \n     2. Drug claim and payment information \n     3. Administration claim and payment information\n\nEach sheet has a unique identifier to guide you in entering the data across the 3 sheets. To enhance ease of use, many fields will populate based on prior information entered or will allow for drop down selections. Therefore, it is necessary to start your data entry with the Patient Information sheet. The dashboard will provide an overview of drug and administration claims submitted, starting with the month of your choice, and an overview of drug and administration claim status (overall or by month). \n\nThis Reimbursement Tracking Log provides tracking of disclosure of patient-protected health information and is meant to be a quick-reference tracking tool limited to the physician’s office. This Reimbursement Tracking Log does not replace any authorization forms that must be filled out by the patient as required by law or public health purposes. To comply with HIPAA requirements, and protect the privacy of protected health information, no information provided herein will be disseminated to any individuals or third parties. Please do not share any patient information with your Biogen Rare Disease Reimbursement Manager.\n\n"]
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[null," © 2018 Biogen.             All rights reserved.              SPZ-US-1496             05/18"]

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[null,null,"SPINRAZA REIMBURSEMENT TRACKING LOG—TEMPLATE"]
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[null,null,"PATIENT INFORMATION"]
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["SP",null,"SPINRAZA REIMBURSEMENT TRACKING LOG—TEMPLATE"]
[]
[]
[null,null,"SPINRAZA - CLAIMS AND PAYMENT DETAILS"]
[null,null,"Patient ID/ Account #","Date of Service","SPINRAZA\n(HCPCS code)","Drug: Amount Charged","Date of Claim Submission","Claim Item Status\n(rejected, pending, denied, approved, appealed)","Notes for Unpaid Claim Items","Payment Date","Amount Allowed\n(total amount allowed by the health plan for the drug)","Amount Paid\n(amount allowed for the drug minus patient responsibility)","Adjusted Amount\n(amount allowed subtracted from the amount charged)","Adjustment Reason Codes\n(reasons for adjustment)","Adjustment per Negotiated Rate\n(YES or NO)","Patient Responsibility\n(procedure deductible, copay, and/or coinsurance amount)","Copay Assistance Amount",null,null,"Copay Assistance Notes"]
[null,1,null,null,"J2326",null,null,null,null,null,null,{"$f":"K6-P6","v":0},{"$f":"$F6-$K6","v":0},null,null,null,null,"Rejected","YES"]
[null,2,null,null,"J2326",null,null,null,null,null,null,{"$f":"K7-P7","v":0},0,null,null,null,null,"Pending","NO"]
[null,3,null,null,"J2326",null,null,null,null,null,null,0,0,null,null,null,null,"Denied"]
[null,4,null,null,"J2326",null,null,null,null,null,null,0,0,null,null,null,null,"Approved"]
[null,5,null,null,"J2326",null,null,null,null,null,null,0,0,null,null,null,null,"Appealed"]
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{"sheet":"Admin Procedure","index":3,"n_rows":255,"n_cols":24,"rows_kept":255,"cut":false,"hidden":false,"merged":[[3,2,3,19],[0,2,2,19]]}
[null,null,"SPINRAZA REIMBURSEMENT TRACKING LOG—TEMPLATE"]
[]
[]
[null,null,"ADMINISTRATION - CLAIMS AND PAYMENT DETAILS"]
[null,null,"Patient ID/ Account #","Date of Service","Administration Procedure\n(CPT code[s] with related modifiers)","Administration Procedure: Amount Charged","Date of Claim Submission","Claim Item Status\n(rejected, pending, denied, approved, appealed)","Notes for Unpaid Claim Items","Payment Date","Amount Allowed\n(total amount allowed by the health plan for the administration procedure)","Amount Paid\n(amount allowed for the administration procedure minus patient responsibility)","Adjusted Amount\n(amount allowed subtracted from the amount charged)","Adjustment Reason Codes\n(reasons for adjustment)","Adjustment per Negotiated Rate\n(YES or NO)","Patient Responsibility\n(procedure deductible, copay, and/or coinsurance amount)","Copay Assistance Amount",null,null,"Copay Assistance Notes"]
[null,1,null,null,null,null,null,null,null,null,null,{"$f":"K6-P6","v":0},{"$f":"F6-K6","v":0},null,null,null,null,"Rejected","YES",null,null,null,null,{"$f":"W6-AB6","v":0}]
[null,2,null,null,null,null,null,null,null,null,null,0,0,null,null,null,null,"Pending","NO"]
[null,3,null,null,null,null,null,null,null,null,null,0,0,null,null,null,null,"Denied"]
[null,4,null,null,null,null,null,null,null,null,null,0,0,null,null,null,null,"Approved"]
[null,5,null,null,null,null,null,null,null,null,null,0,0,null,null,null,null,"Appealed"]
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[null,null,"Select Year:",2018,null,null,null,null,null,null,null,null,2018,{"$f":"IF(AND($D$6=$M$6, $D$7=O6),M6,\"\")","v":2018},"January",0]
[null,null,"Select Starting Month:","January",null,null,null,null,null,null,null,null,2018,{"$f":"IF(AND($D$6=$M$6, $D$7=O7),M7,\"\")","v":""},"February",0]
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