Obtaining Separate Reimbursement for Nutrition Services

Judy StarkV.P. Health Management and Accreditation

CoOportunity Health

Obtaining separate reimbursement for Nutrition Services

• Cannot be services that are part of a package of care that are already reimbursed via another claim– Nutrition counseling/services delivered to patients

in a hospital or SNF under per diem or case rate payments

– Nutrition counseling that is packaged as part of a global medical/surgical package (i.e. bariatric surgery package or OB package) billed by a provider

Obtaining separate reimbursement for Nutrition Services

• Identify health plans that cover nutrition counseling, not all do

• The Affordable Care Act requires Qualified Health Plans (those sold on the Exchanges) to cover the following preventive nutrition services at no cost share to the member:– Counseling and behavioral interventions of obese children

and adults– Intensive healthy diet counseling for adults with high

cholesterol, CVD risk factors, diet-related chronic disease

https://www.healthcare.gov/what-are-my-preventive-care-benefits/

Obtaining separate reimbursement for Nutrition Services

• For healthplans that DO cover nutrition services, determine if they separately credential RDs/Nutritionists to provide these services.

• Some healthplans cover these services but do not credential, and therefore separately reimburse, RDs/Nutritionists.– Some healthplans reimburse for these services when billed

by a medical physician or chiropractic clinic, although the services are delivered by a employed RD/Nutritionist.

Obtaining separate reimbursement for Nutrition Services

• If an RD/Nutritionist wishes to establish an independent practice and bill healthplans that do cover nutrition services and do credential RDs/Nutritionists, they need to:

– Complete an application for network participation, negotiate a provider contract

– Submit their credentialing application for verification and approval– Identify appropriate CPT and billing codes– Identify appropriate billing forms (i.e CMS1500 form)

Additional Resources• https://etools.cooportunityhealth.com/coop-public/coverage-criteria/dietitian-consultation/

• S:\Policies and Procedures\Medical Management Policies\Policy CRED007 Credentialing Program Criteria for Network Participation.docx

• http://www.midlandschoice.com/Provider/Credentialing/Index.html

• https://www.midlandschoice.com/Provider/Credentialing/RequestAnApplication.html

• C:\Users\jstark\SkyDrive Pro\Documents\Presentations\Dietitians Nutritionists\09 ProviderAgreement-Sample.docm

• http://www.wellmark.com/Provider/CommunicationAndResources/PDFs/S5780_ContractsandCredentialingProviderGuide.pdf