JOI 2023 Insurance

Jefferson Outpatient Imaging

Contracted Payers List

Jefferson Outpatient Imaging

Contracted Payers List

YOU MUST HAVE THE FOLLOWING PRIOR TO GETTING A PROCEDURE PRE-AUTHORIZED:

• Patient’s insurance identification number

• Ordering physician’s name and TAX ID #

• Previous treatment– i.e. x-rays, lab work, physical therapy, anti-inflammatories, etc.

• CPT code of the exam being authorized

• Facility information where the exam is being performed—facility name, tax ID # and address

• Diagnosis / symptoms

You may schedule your patient for their exam at Jefferson Outpatient Imaging and then fax the authorization, or obtain the authorization first and fax all required information at one time. We are happy to be your resource for all your precert / preauth questions.

JOI SELF PAY POLICIES

Jefferson Outpatient Imaging welcomes self pay patients and has taken measures to help make our imaging services more affordable to those without insurance. Please call us for further details: 215-503-4900.

HIGH DEDUCTIBLE PLANS

We are unable to offer patients with high deductible plans our self pay discount. Due to our contract agreements with insurance companies, we must submit claims to the insurance carrier. Our self pay discount is for uninsured patients.

BURKS MEDICAL CONSULTING

Request for Authorization

Provider/Referral Office Registration Form

PLEASE FAX THIS COMPLETED FORM TO 866-222-8241

Physician Name ________________________________________

Address ________________________________________________

Phone # _______________________________________________

Fax # __________________________________________________

Specialty _______________________________________________

Contact Person

Tax ID __________________________________________________

NPI ____________________________________________________

Please email us with any questions: joiburks@jefferson.edu

BURKS MEDICAL CONSULTING Request for Precertification

Please email this completed form to joiburks@jefferson.edu ATTACH ALL THREE ITEMS BELOW TO YOUR EMAIL OR PROCESS MAY BE DELAYED. 1.

Please check your patient’s preferred appointment location:

Please provide your contact info. (direct phone #s only - we must be able to reach you):

The following information should be noted on the order form:

Subscriber Name

DX/Reason for Exam/Clinical Notes* ____________________________________________________

Has patient had a previous X-ray? ☐ Yes (Date of X-ray: __________) ☐ No

If yes, were findings positive?

Please email us with any questions: joiburks@jefferson.edu

BURKS MEDICAL CONSULTING Request for Precertification

FOR USE BY JEFFERSON OFFICES ONLY

Please email this completed form to joiburks@jefferson.edu

Please check your patient’s preferred appointment location:

☐ Center City 850 Walnut Street Philadelphia, PA

☐ Collegeville 534 W 2nd Ave Suite 102 Collegeville, PA

☐ Northeast Philadelphia 10160 Bustleton Ave Suite E Philadelphia, PA

☐ East Norriton 1 W Germantown Pike East Norriton, PA

☐ Marlton, NJ 999 Rt 73 North Suite 101 Marlton, NJ

☐ Malvern 650 Carnegie Blvd Suite 240 Malvern, PA

☐ Navy Yard 3 Crescent Drive Suite 1002 Philadelphia, PA

☐ Washington Twp, NJ 243 Hurffville-Cross Keys Rd Suite 102 Sewell, NJ

Please provide your contact info. so we can reach you if we have questions: Name Email or Phone

MRN

Type of Study __________________________________________________

Best Phone # __________________________________________________

Date of most recent clinical note

*Please make sure patient’s updated insurance card has been scanned into their EPIC chart.

Please email us with any questions: joiburks@jefferson.edu

BURKS MEDICAL CONSULTING

When using Burks for authorization assistance with Jefferson Outpatient Imaging, we ask that you please follow these steps:

1. Inform the patient that someone from Jefferson Outpatient Imaging will be calling them to schedule their appointment and that they do not need to call us to schedule.

2. Email the completed Burks form to joiburks@jefferson.edu. Please make sure to include your contact information in the event that we need to reach you.

3. Once we receive the Burks form, we will submit the authorization information within one or two business days.

4. The authoization could take up to 5 business days depending on the insurance carrier. Once we receive the authorization, we will call the patient to schedule.

5. Once the patient is scheduled, we will inform you of the appointment day and time. Our preferred communication is email, however, if providing a phone number, please include a direct line. Jefferson offices: we will contact you via Secure Chat if you list your Jefferson email.

6. Two attempts will be made to reach your patient. If we are unsuccessful, we will notify your office.

Please email us with any questions: joiburks@jefferson.edu