Sample Forms and Letters

Having the right form can help expedite the reimbursement process. Below you’ll find all the forms you need for obtaining verification, ordering Synvisc-One^® or SYNVISC^® (hylan G-F 20) and submitting claims, plus letter templates you can use to confirm prior authorization or request appeals.

Claim Forms

Office Setting
Physicians who administer Synvisc-One and SYNVISC in the office use this claim form to bill Medicare and most other payers.

Sample CMS-1500 Claim Form (PDF)
Blank CMS-1500 Claim Form (PDF)

Hospital Setting (Outpatient)

Physicians who administer Synvisc-One and SYNVISC in the outpatient setting use this form to bill Medicare.

Sample CMS-1450 or UB92 Claim Form (PDF)
Blank CMS-1450 or UB92 Claim Form (PDF)

Sample Letters

Sample Medical Necessity Letter

Some insurers may require written confirmation that a patient has knee pain due to osteoarthritis and has failed to respond to conventional therapies.

Sample Medical Necessity Letter (DOC)

Sample Appeal Letter

This letter template may be used to help you begin the appeals process for a denied claim.

Sample Appeal Letter (PDF)

Additional Forms

Insurance Verification

Verify a patient’s unique coverage and reimbursement with SYNVISC Connection. If you would like to use this service, complete an Insurance Verification Request Form and fax it to 1-800-508-8083 for insurance assistance, including clean claims support.

Insurance Verification Request Form (PDF)

Clean Claims Program

SYNVISC Connection offers comprehensive claim support for your patients. Whether you need us to review a claim, track a claim, or if your patient has received Synvisc-One and the claim was been denied or underpaid, our Regional Appeals Specialists are here to help. If you need claim support, complete the Clean Claims Request form and fax it to 1-800-508-8083.

Clean Claims Request Form (DOC)

Indication

SYNVISC^® (hylan G-F 20) and Synvisc-One^® (hylan G-F 20) are indicated for the treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative non pharmacologic therapy and simple analgesics, e.g., acetaminophen.

Important Safety Information

SYNVISC and Synvisc-One are contraindicated in patients with known hypersensitivity to hyaluronan products or patients with infections in or around the target knee. Use caution when injecting SYNVISC or Synvisc-One in patients allergic to avian proteins, feathers, or egg products; who have evidence of venous or lymphatic stasis in the leg to be treated; or who have severe inflammation in the knee to be treated.

Patients should be advised to avoid strenuous or prolonged weight-bearing activities for approximately 48 hours after treatment. Aspiration of any effusion prior to injection is highly recommended. Strict adherence to aseptic technique must be followed to avoid joint infection. The safety and effectiveness of SYNVISC and Synvisc-One have not been established in children or in pregnant or lactating women. It is unknown whether SYNVISC or Synvisc-One is excreted in human milk.

For SYNVISC
In clinical trials, the most commonly reported adverse events were transient local pain, swelling, and/or effusion in the injected knee. In some cases, these symptoms have been extensive. Other side effects such as rash have been reported rarely.

View the Complete Prescribing Information for SYNVISC (PDF)

For Synvisc-One
The most commonly reported related local adverse events were transient, mild-to-moderate arthralgia, arthritis, arthropathy, injection site pain and joint effusion. No serious adverse events were reported in clinical trials in knees injected with Synvisc-One. Serious local adverse events have been reported only rarely in post-marketing use. Repeat treatment did not affect the safety profile. In the pivotal clinical trial, there was one related systemic event of syncope. The most common systemic side effects irrespective of relationship to Synvisc-One were headache, back pain, nasopharyngitis and influenza. Systemic adverse event profiles were similar between patients in the Synvisc-One and Saline Control groups.

View the Complete Prescribing Information for Synvisc-One (PDF)