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Between June 2009 and December 2009, members of the Reimbursement Committee contacted the below health care insurance companies to ask about reimbursement for nutrition services. The following info was ascertained. Coverage policies may change in 2010. Each contract offered by the insurer may have different coverage for co-pays and coverage of nutrition counseling, thus the practitioner or client should double check with the insurer before providing service. A primary care physician referral for nutrition counseling is required.

MassHealth

http://www.mass.gov/masshealthpubs


Information below was derived from Physician Bulletin 86, July 2007, which also provides CPT codes and billing info:

http://www.mass.gov/Eeohhs2/docs/masshealth/bull_2007/phy-86.pdf

  • MassHealth covers MNT (Medical Nutrition Therapy) & DSMT (Diabetes Self-Management Services) provided by licensed dietitians under the supervision of a physician (e.g.: in the setting of a physician office, community health center or acute outpatient hospital). These services can only be provided by a physician, community health center, or acute outpatient hospital.
  • MNT and DSMT are payable to a physician when provided by midlevel practitioners (e.g.: licensed dietitian) under the supervision of that physician. Supervising physicians must ensure that mid-level practitioners possess the appropriate credentials and training.
  • When an individual qualifies for MassHealth, they are allowed to choose from a group of approved health insurers who provide this option (e.g.: BMC Health Net) or community providers (e.g. Manet Community).
  • MassHealth does not credential Dietitians or Nutritionists. Therefore these services cannot be billed by private practice dietitians using their own provider number.

Harvard Pilgrim

1-800-708-4414

https://www.harvardpilgrim.org/portal/page?_pageid=1391,1&_dad=portal&_schema=PORTAL

  • Harvard Pilgrim does cover nutrition services offered by a dietitian or health care facility, provided the dietitian is an approved provider. A physician referral is required prior to the service, and the number of visits allowed is dependent upon the physician referral. The referral is filed electronically, so the practicing dietitian may not receive a copy of this.
  • Obtaining a provider number for Harvard Pilgrim:
    • To apply, send a letter of intent to FAX: 617 509-0205.
    • Include your Name, credentials, NPI#, practice tax ID#/EIN, name and address, billing info, and W9 IRS form. Then wait 60-90 days. You will either receive a rejection if geographical area is full or a packet with contract and agreement papers.

Blue Cross Blue Shield

BCBS MA Landmark Center 401 Park Dr. Boston, MA 02215

1-800-316-2583 x 64316

http://www.bluecrossma.com/common/en_US/medical_policies/375%20Medical%20Nutrition%20Therapy%20prn.pdf

  • BCBS does cover nutrition services and diabetes self-management education when offered by a provider dietitian or health care facility.
  • A physician referral is required prior to the service, and the number of visits allowed annually may be limited (was verbally told 6 per year, but it is possible to request more visits if warranted by filling out an authorization request form along with the clinical notes. It may take a week to receive an approved/denial response.
  • A member of our committee who has a private practice noted difficulties in being reimbursed by BSBS other than Massachusetts BCBS.


Tuft’s Health Plan

1-888 884-2404

http://www.tuftshealthplan.com/providers/provider.php

  • Tuft’s does cover nutrition counseling and diabetes self-management education when offered by a provider dietitian or health care facility, but coverage will vary based on the individual’s contract.
  • Referrals are needed for all contracts except for the GIC Navigator, which only allows only 3 visits per year.

Aetna

1-866-707-0628

http://www.aetna.com/cpb/medical/data/1_99/0049.html

  • Aetna does cover nutrition counseling, but coverage will vary based on the individual’s contract.
  • Aetna Clinical Policy Bulletin:
    • Nutritional Counseling states:
      • Aetna considers nutritional counseling medically necessary for chronic disease states in which dietary adjustment has a therapeutic role, when it is prescribed by a physician and furnished by a provider (e.g., a registered dietician, licensed nutritionist or other qualified licensed health professional such as nurses who are trained in nutrition) recognized under t plan.
      • Aetna considers nutritional counseling of unproven value for conditions that have not been shown to be nutritionally related, including but not limited to chronic fatigue syndrome and attention-deficit hyperactivity disorder.
      • Note: In all circumstances, the intent of this policy is to permit the nutritional counselor to function as a consultant to evaluate the member and coordinate ongoing care with the referring physician.

Fallon Community

1-866-ASK-FCHP (866-275-3247)

askfchp@fchp.org

http://www.fchp.org

  • Fallon Community Health Plan (FCHP) will reimburse for the covered professional services provided by registered dietitians (RD) or licensed/certified nutritionists who are participating through a contracted entity and are within the legal scope of their practice. Each state is responsible for mandating and enforcing specific requirements for licensure and for defining the legal scope of practice.
  • The registered dietitian's (RD) or licensed/certified nutritionist's Medicare PIN must be submitted in item 33 of the CMS-1500 form. The referring physician’s name must be submitted in item 17 of the industry standard forms. Fallon Community Health Plan’s payment for all services provided by registered dietitian (RD) or licensed/certified nutritionist is 85 percent of the applicable physician fee schedule amount, or as per contract.
  • The following CPT codes should be used:
    • 97802 – Medical Nutrition Therapy (MNT) Initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes.
    • 97803 – MNT reassessment and intervention, individual, face-to-face with the patient, each 15 minutes 97804 – MNT group, 2 or more individuals, each 30 minutes
    • S9470 – Nutritional counseling, Dietitian visit

United Healthcare

1-877-842-3210 Option 5 (professional services) and then Option 1 (credentialing)

  • Nutritional counseling services provided by a dietitian (a licensed health professional) to develop a dietary treatment plan to treat and/or manage conditions such as diabetes, heart failure, kidney failure, high cholesterol etc. are Covered Heath Services when both of the following are true:
    • Nutritional education is required for a disease in which patient self-management is an important component of treatment.
    • There exists a knowledge deficit regarding the disease which requires the intervention of a trained health professional.
  • The benefit for eligible nutritional counseling depends on the place of service.
    • When provided in an office place of service the benefit is under the Physician’s Office Services – Sickness and Injury benefit.
    • When provided in an outpatient hospital or facility place of service the benefit is under the Therapeutic Treatments Outpatient benefit.
  • Nutritional Counseling Non-disease specific, nutritional education such as general good eating habits, calorie control or dietary preferences (e.g. vegetarian, macro-biotic) is excluded from coverage.
  • Enteral feedings (Enteral formula) are excluded from coverage. The only exception to this exclusion is for state mandates that require coverage for Enteral formula for certain diagnoses. The Enteral formula exclusion does not apply to eligible Durable Medical Equipment that is used to administer the formula, such as Enteral pumps and tubing.
  • Infant formula and donor breast milk are excluded from coverage. The only exception to this exclusion is for state mandates that require coverage for infant formulas for certain diagnoses. There are no exceptions for donor breast milk. Breast Pumps are excluded from coverage as they do not meet the definition of DME.
  • Nutritional or cosmetic therapy using high-dose or mega quantities of vitamins, minerals or elements and other nutrition based therapy are excluded from coverage. Examples include supplements, electrolytes, and foods of any kind. This includes, but is not limited to: high protein foods, low protein foods, and low carbohydrate foods.