PRACTICE RESOURCES

Explore Helpful Resources for your
Practice and Patients

Program Overview Brochure

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This brochure provides an overview of the support services provided by CIMERLI Solutions. There is information regarding the co-pay savings program, the patient assistance program, the field reimbursement managers as well as the billing and reimbursement support available.

Enrollment Form

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This form is the first step in enrollment into the Coherus SolutionsTM Program. Please complete this form if you are interested in benefit verification, appeals support, or the co-pay savings program.

PAP Enrollment Form

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This form should be used to enroll your patient into the patient assistance program.

Patient Consent

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This form may be used to obtain patient consent to disclose personal information in order to enroll into patient access programs.

Sample Coding Sheet (CMS 1450 form for Hospital Inpatient Claims)

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The sample claim forms provide an example of how a claim form may look when billing for CIMERLI. The UB-04 (CMS-1450) form should be used in the hospital outpatient site of care.

Sample Coding Sheet (CMS 1500 form for Outpatient Claims)

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The sample claim forms provide an example of how a claim form may look when billing for CIMERLI. The CMS-1500 should be used in the physician office or clinic.

Coding Reference Guide

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This coding guide provides overview of the billing codes associated with CIMERLI that may help you submit health insurance claims. This coding guide does not guarantee payment for CIMERLI. Please check with the payer to confirm the appropriate codes and any treatment approval requirements.

Product Fact Sheet

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This fact sheet provides a snapshot of important information related to CIMERLI including ordering and package information and coding and billing information.

Letter of Medical Necessity

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Prior to utilizing CIMERLI, the payer may require a prior authorization or a letter of medical necessity. This is a sample letter of medical necessity that may be used as a guide.

Letter of Appeals

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The letter of medical appeal may be helpful if you have received a denial from your patient's health insurance. Please review to determine what information should be included in an appeal.

Product Replacement Request Form

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Product Replacement Guidelines

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Patient Assistance Refill Request Form

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Virtual Debit Card Fax Request

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Have questions?

For questions regarding CIMERLI™ resources, call CIMERLI Solutions™ at 1-844-483-3692.