Approval Letter Requirements

The following is a list of information that DynaVox Technologies requests to be included in an insurance company's letter of approval. The information (when provided) eliminates the need for the client/patient to pre-pay DynaVox Technologies for the total amount of the requested equipment. When applicable, DynaVox Technologies does require the client/patient to pre-pay co-payments, co-insurance, deductibles, out-of-pocket maximums, etc. The letter must:

• Be on the Insurance Company's letterhead and addressed to DynaVox Technologies.
• Refer to the client/patient's: name; policy and/or group number; authorization and/or claim number.
• State that, "Any applicable payments will be made to DynaVox Technologies directly" (given that DynaVox Technologies has provided an assignment of benefits).
• Give the exact equipment (including device and/or accessories) with the retail price that has been approved, and list any equipment that has been denied.
• Give the applicable claim/billing address and procedure/billing code.
• Give the claim/billing instructions if claim/billing cannot be submitted on the HCFA1500.
• Give the phone number(s) to check eligibility of coverage and benefits.
• Be signed by an insurance company employee with the authority to sign the requested letter (please include the title and phone number of the employee).
• Give the exact amount, if available, of the total bill to be paid by the insurance company.
• State the client/patient's financial responsibility for approved equipment (including, but not limited to: co-payments, co-insurance, deductible (family and individual), out of pocket maximums, etc.) Note: If possible, please give the amounts met for each of these categories to prevent DynaVox Technologies from having to collect the full portion upfront.
• State overall benefits for client/patient's policy, including: percentage of equipment that will be covered; maximum allowance/benefit amount for the approved equipment; maximum out-of-pocket and/or stop-loss for the approved equipment; whether deductible, co-payment, co-insurance, etc is included in the maximum out-of-pocket/stop-loss, etc. for this policy.
• State whether the above client/patient financial responsibility and benefits are quoted based on participating provider/in-network benefits or non-participating provider/out-of-network benefits. Note: DynaVox Technologies is not a participating/in-network provider.

Upon receiving any overpayment, DynaVox Technologies will reimburse the necesary party. Should DynaVox Technologies be underpaid, the policyholder will be responsible to pay any balance due immediately.