RESOURCES
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OMIDRIAssure® Flashcard
Overview of the OMIDRIAssure program
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We Pay the Difference Submission Form
To enroll patients in the We Pay the Difference patient reimbursement program for commercially insured patients
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OMIDRIAssure Patient Certification Form
To determine patient eligibility for the Equal Access patient assistance program
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Ordering Information Sheet
Wholesaler/distributor and billing information for OMIDRIA
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Reimbursement Guide
An important office guide to coding and billing for OMIDRIA, including sample claim forms
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Procedure Guide
Storage, preparation, and administration information for OMIDRIA
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ASC Payment Schedule
Click here and select the latest quarterly ASC payment rate addenda for current ASC payment information
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HOPD Payment Schedule
Click here and select the Addendum A and Addendum B Updates option. Select the latest quarterly Addendum B payment schedule for the current HOPD payment information
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Letter of Medical Necessity Sample
Template letter used to communicate with payers. Can be customized to establish the medical reason OMIDRIA was used with a patient
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Letter of Appeal Sample
Template letter used to communicate with payers. Can be customized to appeal a payer’s decision not to reimburse the use of OMIDRIA with a patient
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