ORDERING INSTRUCTIONS

Amprion is committed to ensuring that every patient can have access to the SAAmplify™-ɑSYN Test.

Medicare

• Amprion is a Medicare participating provider, however it is possible that Medicare will not cover the SAAmplify™-ɑSYN Test.
• If Standard Medicare covers your healthcare, you will be asked to complete a Medicare ABN (Advance Benefit Notification) to acknowledge, if denied, you will be held financially responsible for the test.
• Patients who are covered by a Medicare Advantage Plan may also need to sign an ABN, or Amprion consent form, which would need to be submitted with the specimen.

Medicaid

• Amprion is not a Medicaid provider. Medicaid will not pay for this service at this time.

Insurance

• As a courtesy Amprion will bill your primary insurance company if we are provided with complete insurance information.
• Our billing staff will assist you in any way we can to help get your claim paid, however, we cannot predict the level of reimbursement that will be approved.
• Your insurance company may need you to provide certain information directly before processing your claim. If this happens, please respond to them as quickly as possible. Amprion may also need this information. Please call Amprion at (877) 926-3447 M-F 7AM-5PM MST and let us know what information was requested. It is your responsibility to comply with your insurance requests.
• If you receive an Explanation of Benefits (EOB) from your insurance, please note that THIS IS NOT A BILL. It is an explanation of how they processed your claim. If you receive this, please call Amprion at (877) 926-3447 M-F 7AM-5PM MST so that we can help review the document with .
• The SYNTap test that your doctor considers medically necessary to aid in the diagnosis of certain neurodegenerative disorders, may not be covered by insurance for one or more reasons. This may include but is not limited to exclusions from your insurance plan, an insurance plan’s designation of Amprion as an out-of-network provider, and/or failure to obtain an authorization or referral for the test.
• Your health plan may also determine that, based on the design of your plan, you are responsible for a deductible, copayment and/or coinsurance or non-covered services. Patients are held financially responsible for these charges.

Uninsured or Self-Pay Patients

• If you do not have insurance or would prefer that Amprion not submit a claim to your insurance, Amprion offers a reduced cash pay option.
• You will be invoiced directly, and payment is due upon receipt of the initial bill.
• Under certain specified circumstances uninsured and self-pay patients have the right to request a “good faith” estimate before obtaining the test. If you would like to discuss this, please reach out to Amprion at:
  • (858) 461-6338 Option 3 or
  • ClientServices@AmprionDx.com

Amprion Payment and Financial Programs

• Amprion’s payment and financial programs are only available to patients who reside within the United States and U.S. territories.
• Amprion offers six-month interest free payment arrangements.
• Patients who are experiencing economic hardship may qualify for financial assistance that is based on:
  • Percentage of the current Federal Poverty Guidelines.
  • Completion of a financial assistance application.
  • Patients can be evaluated for financial assistance before testing has begun, during the insurance billing process or after insurance has processed the claim.

As with any type of bill, it is important to pay for your test promptly. Payment is due upon receipt of your statement unless prior arrangements have been made with the Amprion billing staff.

• Mail: Send your payment by check or money order to the address below (also shown on your statement). Please include your Account Number on the check or money order.

Amprion Inc.
ATTN: Billing Department
PO Box 95970
South Jordan, UT 84095-0970

If you have received a check from your insurance company:

1. Sign the back of the check with “pay to the order of Amprion Inc.”
2. Include a copy of your EOB (Explanation of Benefits)
3. Mail to the Amprion address listed above.

• Credit card payment may be made by phone using our automated system by calling our toll-free number at (877) 926-3447 and choosing option 1, or online at PayPBO.com (https://paypbo.com)c