North Carolina Health and Wellness Trust. Registered Dietitian Billing Guide

Transcription

1 North Carolina Health and Wellness Trust Registered Dietitian Billing Guide 2011 IN4Kids Project Any opinion, finding, conclusion or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view and policies of the North Carolina Health and Wellness Commission. 1

2 Table of Contents I. Introduction 4 II. National Provider Identifier, Credentialing, and Council for Affordable Quality Healthcare 6 Obtaining a National Provider Identifier 8 Credentialing with Insurance Companies 10 What is the Council for Affordable Quality Healthcare? 17 III. Insurers and Coverage, Procedure Codes, and Diagnosis Codes 28 Insurers and Coverage 28 CPT or Procedure Codes 54 ICD-9-CM or Diagnosis Codes 55 IV. Verifying Insurance Coverage and Benefits 57 V. Filing Insurance Claims 64 Understanding CMS 1500 forms 66 Electronic Claims Submission 74 VI. Reference Contact List 82 VII. Appendix 84 VIII. Index 88 2

3 This manual was written by: Jaime Lynn Lewis, RD, LDN Owner Contemporary Nutrition, Inc. Havelock, NC Gwen Murphy, MS, PhD, RD, LDN Assistant Consulting Professor Division of Community Health Department of Community and Family Medicine Duke University Medical Center Durham, NC Kathryn Kolasa, PhD, RD, LDN Professor and Section Head Nutrition Services and Patient Education Brody School of Medicine Department of Family Medicine East Carolina University Greenville, NC Pam Michael, MBA, RD Director, Nutrition Services Coverage American Dietetic Association Chicago, IL Kim Koltzau, RD, LDN Program Manager Take Charge Weight Initiative Guilford Child Health, Inc. Greensboro, NC We would like to thank the following for their helpful comments in preparing this guide: Sheree Vodicka, Betsy LaForge, Shelia Garner, Karyn Evans, Cara Elio, Mia Chabot, Andrea Nikolai, Heather Foster, Rachel Kroll, Melissa Smith, Nidu Menon, Cameron Graham, Anthony Meachem, Josephine Cialone, and Cathie Ostrowski. 3

4 I. Introduction This billing guide is intended to assist registered dietitians, medical practitioners, practice managers, billing personnel, and practice plans in the intricacies of reimbursement for medical nutrition therapy (MNT) particularly with regard to obesity. It was developed with funding from the North Carolina Health and Wellness Trust Fund. North Carolina has been a leader in providing reimbursement for MNT. Starting in 2003, the Health and Wellness Trust Fund Chair (then) Lt. Governor Beverly Perdue established a committee to study childhood obesity. The task of this committee was to understand the causes of childhood obesity and to develop recommendations to combat this epidemic. Starting in 2005, Blue Cross and Blue Shield of North Carolina (BCBSNC) began covering MNT as part of its Member Health Partnership obesity-related health management program. Medicaid of North Carolina started covering MNT for obesity in In 2010, as this manual was written, NC State Health Plan and Federal Health Plan added MNT benefits for children who are overweight or obese. In 2009, the Alliance for a Healthier Generation initiated a childhood obesity program that provides eligible children with access to at least four visits with their primary care provider and at least four visits with a registered dietitian. The Alliance convened medical associations, including the American Dietetic Association, insurers and employers to encourage them to provide obesity benefits such as MNT for children and families. Prevention and treatment for obesity is an important benefit to dovetail with the policy and environmental changes that are currently being promoted across the country. Additional details on the Alliance Healthcare Initiative are available at Members of the American Dietetic Association can review RD-specific information for participating in the Alliance Healthcare Initiative by accessing information located at MNT coverage provided by RDs also became effective in 2003 in the federal Medicare Part B program. Currently, coverage is limited to qualifying Medicare beneficiaries with diabetes, chronic kidney disease and post-kidney transplants. Unfortunately, there is no uniformity between and even within insurers with regard to benefits, billing and reimbursement for RDs. This manual was developed under a contract with the North Carolina Health and Wellness Trust Fund to support the efforts of registered dietitians, both in private practice and working in ambulatory healthcare facilities and clinics, to create and implement a business model that will allow them to provide covered nutrition services. This manual includes both information that is available by searching documents and web sites of various insurance providers and information from conversations with insurers. It also provides real-life experiences of North Carolina registered dietitians as they completed 4

5 local health plan s credentialing requirements in order to receive direct reimbursement for the delivery of MNT. We have sought to make this information as accurate and current as possible but cannot be held responsible if the information has changed. Insurance plans and procedures change rapidly and it is the responsibility of the provider to keep up to date on these. Section 2 provides instructions for obtaining a national provider identity and becoming credentialed with insurers. Section 3 outlines nutrition services covered by local insurers and it reviews both Current Procedure Terminology codes (CPT) and diagnostic codes (ICD- 9). Section 4 details how to verify coverage and what information the RD should collect from patients prior to the provision of MNT services. And finally, Section 5 provides the ins and outs of filing insurance claims. 5

6 II. National Provider Identifier, Credentialing, and Council for Affordable Quality Healthcare After years of college to complete your degree, your licensure exam, and career planning, there are just a few more steps that you must complete to be reimbursed for Medical Nutrition Therapy. You must apply for a National Provider Identifier (your individual identifying number) and then you must credential (apply to become a provider) with each insurance company. The following pages will explain the details that are involved. While you complete these steps, you may receive payment directly from the patient. National Provider Identifier (NPI) What is a National Provider Identifier? The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers and health plans. The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. This is an individual identifying number, much like your social security number. The National Provider Identifier or NPI is a 10-digit, intelligence free numeric identifier (10 digit number). Intelligence free means that the numbers do not carry information about health care providers, such as the state in which they practice or their provider type or specialization. Each time you credential with an insurance company, they will attach your NPI to your name and specialty. Your NPI will not change and will remain with the provider regardless of your job, location, or name changes. What is the NPI used for? The purpose of the NPI is to uniquely identify a health care provider in standard transactions, such as in coordination of benefits between health plans, health care claims, and in patient medical record systems. Each time you call an insurance company to verify benefits, they will ask you for your NPI number. (If it is an out-of-state plan, there are times when they cannot find you in their system, so don t be surprised. You will need to give them your NPI number, name, address, and specialty information.) Every claim that is filed will have your NPI number on the CMS 1500 form (**See page 73 CMS 1500) whether handwritten or electronic. Many of the medical record systems use your NPI number as part of your signature or sign in process. Is there a fee to obtain an NPI number? No. There is no fee, only a registration process. How long will it take to get an NPI? The electronic process online will usually issue an NPI number within minutes but may take up to 10 days from the time you apply to get a return with your NPI number. Completing the process through the mail will take longer. 6

7 Tips to expedite your NPI online application User IDs cannot be changed. (User ID must be 6-12 characters in length, cannot contain any spaces or special characters and cannot contain more than 4 digits. Password must be 8-12 characters long, contain at least one letter, one number, no special characters, and not be the same as the User ID.) Once you have successfully chosen a User ID and secret question/answer combinations and submitted the record, the User ID and secret question/answer combinations will remain tied to your record. Use the application s navigation buttons, NEXT or PREVIOUS. Do NOT use the browser s buttons, BACK and FORWARD. If you have a problem with the system and cannot continue, wait 20 minutes before logging on again. Print each page as you complete the application to keep a record of your file. Assure that you have plenty of time to complete your application. If you leave before your application is complete, you will have to start over. Selected Glossary An Employer Identification Number (EIN) is assigned by the Internal Revenue Service (IRS) (**See page 25 EIN) A Social Security Number (SSN) is assigned by the Social Security Administration. The SSN is furnished only on an NPI application from providers who are individuals. An SSN is required on all web NPI applications. Where would you apply for an NPI? Apply online at 7

8 Obtaining a National Provider Identifier Step 1: Make sure you have all the needed information Before you begin, make sure you have the information in the table below. This information will be required to complete the NPI Application Form. Step 2: Read the 5 statements on the website about truthfulness, verification and privacy. Step 3: Begin on-line application You will not be able to save your work if you quit before you have completed the application form. Information Required for Individual Providers Provider Name SSN Provider Date of Birth Country of Birth State of Birth (if Country of Birth is U.S.) Provider Gender Mailing Address Practice Location Address and Phone Number (you cannot use a PO Box or Residential Address unless it is your Practice address) Taxonomy (Provider Type) (Note: RDs should select the provider type Registered Dietitian - 133V00000X ) State License Information (Your license number from the NC Board of Dietetics) Contact Person Name Contact Person Phone Number and Information Required for Organizations Organization/Business Name Employer Identification Number (EIN) (if you have one registered with the IRS) (**See page 25 How to obtain an EIN) Name of Authorized Official for the Organization Phone Number of Authorized Official for the Organization Organization Mailing Address Practice Location Address and Phone Number (you cannot use a PO Box or Residential Address unless it is your Practice address) Taxonomy (Provider Type)(Note: RDs should select the provider type Registered Dietitian - 133V00000X ) Contact Person Name Contact Person Phone Number and 8

9 How would you deactivate your NPI number? You should contact the NPI Enumerator if you want to deactivate your NPI. Health care providers, including physicians and non-physician practitioners, can deactivate their NPIs if the NPIs are no longer required or needed. Reasons for deactivation include retirement, business dissolved, or death of the health care provider. Centers for Medicare and Medicaid Services (CMS) has contracted with Fox Systems, Inc. to serve as the NPI Enumerator. The NPI Enumerator is responsible for dealing with providers on issues relating to unique identification. Enumerator staff will be available to assist health care providers with questions regarding the processing of an NPI application. The NPI Enumerator may be contacted as follows: By phone: (NPI Toll-Free) (NPI TTY) By By mail: NPI Enumerator PO Box 6059 Fargo, ND

10 Credentialing with Insurance Companies Why would you want to become credentialed with an insurance company? As recent studies have shown the importance of diet in both preventing and managing disease, many insurance companies have moved toward providing a nutrition and/or weight management benefit for its members. For some third party providers, being licensed or registered as a dietitian may be sufficient. For some companies, the dietitian needs only to be working for a physician that is credentialed by a specific third party payer. Example: Blue Cross Blue Shield of North Carolina requires licensed registered dietitians to be credentialed and contracted in order to become in-network providers of MNT. Medicaid/Medicare does not credential the registered dietitian. Under Medicaid in North Carolina only the physician will need to be credentialed. **See pages BCBSNC Credentialing) For other companies, they may want evidence of experience in providing a particular type of medical nutrition therapy and may require credentialing. Insurers are required to verify that RDs selected to participate in their network possess the necessary education, including continued education, license(s), malpractice coverage, a clean criminal record, skills to provide medical nutrition therapy, and letters of recommendation. Some insurers may set additional criteria such as a specific length of time that you have practiced in that state or the need for specific certifications such as Certified Diabetes Educator. Example: Blue Cross Blue Shield of North Carolina requires registered dietitians to have practiced as a licensed dietitian in North Carolina for at least 1 year prior to becoming credentialed. When do you start the insurance credentialing process? You will want to start the credentialing process at least six months prior to seeing your first patient. Insurance carriers can take up to 60 days to review your application and if there is missing information or missing documents, it may be denied therefore taking longer. State law dictates the timeframe insures have to process credentialing applications. The following links includes information outlining some of the regulations that cover the provider credentialing process: North Carolina Administrative Code - Title 11 Chapter 20 (Sections.0401,.0403, 0405,.0407): foldername=\title%2011%20- %20Insurance\Chapter%2020%20- %20Managed%20Care%20Health%20Benefit%20Plans North Carolina General State Statue : html 10

11 How do you know which insurance companies you would like to credential with? The first step is to identify which insurance companies are popular in your area. If you work for a clinic, the business manager or billing office should be able to tell you which insurers are most common for that practice. If you are in private practice, one option is to contact local primary care practices to see which insurances they accept. These will be your referring physicians and you will want to meet their needs. Start with one or two insurance companies at a time. Each insurance company is different in patient criteria, visit criteria, filing processes, and reimbursement. Do not overwhelm yourself by credentialing with too many at one time, because this may lead to mistakes and inevitably loss of revenue. Another option is to compare notes with colleagues in your area to see which health plans credential registered dietitians, and who provides reimbursement for MNT with a Registered Dietitian, who reimburses in a timely manner, and which carriers might be at capacity with providers in your specialty. For those who work in an established practice, you will want to speak with the office manager or person in charge of coding and billing to identify the groups that cover patients seen in that practice. How do you credential with an insurance company? Each insurance company is different in the credentialing completion process. Some insurance companies, like Blue Cross and Blue Shield may require that you go through the local or home plan* because you will be working with local provider relations (**See page 23 Contracting & Provider Relations) and using the local filing processes. Some facilities may have internal credentialing policies. Example: ECU Physicians is a Delegated Credentialing Entity. This means they credential their own providers and allow our commercial carriers to audit their credentialing policies and procedures. Their providers complete the Uniform Application to be processed and approved internally. *A patient s home plan is the health plan in the state where the policy was contracted. For example, the patient s home plan may be with Blue Cross and Blue Shield of Michigan but the patient is currently in North Carolina.. With Blue Cross and Blue Shield, you will file all of your claims directly with your local North Carolina Blue Cross Blue Shield. If the policy is from a state other than North Carolina, Blue Cross Blue Shield of North Carolina s Inter-Plan Programs Department (BlueCard) will be responsible for processing the claim in accordance with the subscriber s benefits through their home plan. However, payment to you is determined by your negotiated rates with BCBS of North Carolina. 11

12 Example: Credentialing Blue Cross and Blue Shield ( Credentialing Instructions-Licensed Dietician Nutritionist (LDN) Dear Health Care Provider: The "Uniform Application to Participate as a Health Care Practitioner", developed by the North Carolina Department of Insurance pursuant to North Carolina General Statute must first be completed to begin the credentialing process. The following instructions will help you to avoid delays associated with an incomplete application. Please review this material carefully before attempting to complete the Uniform Application. Fill in all required information completely and attach all required documents before submitting your application. Blue Cross and Blue Shield of North Carolina (BCBSNC) will notify you of an incomplete application within 15 days of its receipt requesting the information to complete your application. Your incomplete application will be closed 60 days from receipt if the requested information is not received. Upon completion of the credentialing process, you will be presented to the Credentialing Committee for approval or denial. If denied you will be notified by certified mail. If approved you will be notified by BCBSNC s Network Management informing you of your effective date to see BCBSNC managed care members. ALL APPLICANTS: Note all fields must be COMPLETED or indicate NOT APPLICABLE (NA) Provide education/practice history from beginning of your education in your field of expertise up to your current practice location (must include months/years and account for any gaps greater than three months). This information may be submitted on your Curriculum Vitae (CV) and reference sections B 1-5 of the application as "see attached CV". Complete all gaps (e.g. If you got married, had a baby, continued your education, moved, etc.) Be specific with the information that you complete in this application. 1. Copy of CV to include all work history after graduation from appropriate school (CV must account for any gaps of 90 days or more) 2. Certificate of Insurance of at least $1 million per occurrence and $3 million aggregate. Copy of the face sheet of your current professional liability insurance policy, indicating by name, provider(s) covered, coverage amounts, effective date, expiration date, and policy number. (**See page 27 Professional Liability Insurance) 3. The original, unaltered Attestation Statement containing the provider s original signature and date must be submitted with your application. 12

13 Blue Cross and Blue Shield of North Carolina requires two letters of recommendation or two provider evaluation forms (or a combination of the two) from the following providers. These evaluations must come from clinicians licensed to practice in the State of North Carolina who are not a partner or family member of the applicant and who have knowledge of the applicant s good standing and clinical proficiency over the past twelve (12) months. Each letter or form must be dated within two years of the date of the Credentialing Committee review: one letter or provider evaluation form from a physician one letter or provider evaluation form from a peer Oftentimes, you may not have direct contact with a physician and may not have other colleagues directly working with you. This is especially true if you are just starting in a practice. You may use a local referring physician if you have an established practice or you may use a physician or mentor dietitian from your internship if you have not established practice. If you use a substitute for the requested letter, add a note with explanation. All of this information should be submitted to the BCBSNC Credentialing Department at the address listed below. Please contact the Credentialing Department at (919) with any questions: BCBSNC Credentialing P.O. Box 2291 Durham, NC Uniform Application The Uniform Application is the credentialing application form approved by the North Carolina Department of Insurance, in accordance with North Carolina General Statute Every insurer that provides a health benefit plan and credentials providers for its network is required to use this form for credentialing providers. You may choose to complete this form with each individual insurance company you apply with (which may take up to 2-4 months to process) or you may choose to use CAQH to complete this application one time and make it available to each insurance company that you choose to credential with. (The Council for Affordable Quality Healthcare or CAQH has developed an online service intended to eliminate the need for multiple insurance credentialing submissions.(more information on CAQH on page 17) In addition to this application, RDs will need to complete a contract with each insurance company along with other requested provider materials. Once you open the Uniform Application, in addition to the above information, it will also request: Copy of the provider s original state(s) license(s) and current registration. Copy of certificate from the Specialty Board. (If you have any special certifications.) Copy of W-9 Form 13

14 Tips for completing the Uniform Application form ( Explanation is provided below on some of the questions included in the Uniform Application form where RDs have sought out clarification in order to successfully complete the application. Comments regarding questions that are more straightforward are not listed below. Section A: Demographic and Personal Data Question 3 - Check specialist box and list dietitian/nutritionists on the form Question 5 - For your response about whether your office is handicapped accessible, think about whether someone in a wheelchair would be able to access your office. Indicate yes or no. Some insurances have clear criteria such as Is there wheelchair access with a ramp? Allowances are usually made for older buildings, where a patient can be accommodated with assistance. Regarding your office hours, be specific. Even if you do not have office hours for one or more of the days listed on the form, indicate a response, e.g. no office hours available, By appointment, or Not Applicable or NA. Question 9 - RDs have indicated either Not Applicable or NA or indicated they are accessible via pager, blackberry, phone or answering machine for 24 hour/7 day coverage. Question 10 - If you do not have office support (this is usually applicable to RDs in private practice) list self for the administrative contact. Question 12 - RDs do not have UPINs so indicate Not Applicable or NA for that question. Question 13 - A DEA number is a series of numbers assigned to a health care provider (such as a medical practitioner, dentist, or veterinarian), allowing them to write prescriptions for controlled substances. This does not apply to RDs, so indicate Not Applicable or NA for this question. Question 14 - The question about South Carolina licensure (which starts with a gray box after Question 13) should not apply to RDs, so indicate Not Applicable or NA. 14

15 Question 15 - This question may be Not Applicable or NA for all sections of the question (a. d.) unless the RD has specialty credential, for example, Certified Diabetes Educator or one of the Commission on Dietetic Registration board certified specialists. Question 16 - RDs have listed professional memberships in the American Dietetic Association, the North Carolina Dietetic Association, the American Diabetes Association and other similar professional groups in this section. Question 17 & 18 - These questions pertain to MDs. Indicate Not Applicable or NA. Section B: Education and Practice History Question 1 - List undergraduate school information here. Note, in certain instances, you may need to submit verification from the undergraduate program that the program was accredited to provide the dietetics curriculum. Question 2 - List the dietetic internship, coordinated program or approved professional program here. Question 3 & 4 Not applicable to RDs unless the RD completed formal academic training through a specialized nutrition residency program. Question 6 - RDs can list their continuing professional education completed over the last 3 years as CME- (continuing medical education). Note: Some RDs who have completed the credentialing packet listed some but did not list every program that they attended and BCBSNC accepted this information. Some RDs indicated that they Completed ## CPE in a 5 year period. Remember, if your CV includes a detailed description of your education and work/employment history, in the Section B: Education and Practice History on the application form; you can indicate see attached CV for sections B1-5 on the Uniform Application form. 15

16 Section C: Professional Information Check yes or no to the 11 questions included in this section. For any question where you indicated yes complete the corresponding question on the Supplemental Form. If you indicated no, indicate Not Applicable or NA for the Supplemental Form. Make sure that your name is listed on every page of the supplemental form. Remember to sign and date Section C of the application form. Attestation Statement All boxes in this section of the form must be filled in. Every box will read the same. This will be the name of the insurance company that you are applying with. (e.g. BCBSNC, Aetna, Cigna) (**See page 21 Attestation Form) Remember to both print and sign your name and include the date at the end of this section of the form. Recredentialing Periodically, you will need to recredential with the insurance company. This typically is required every three years. Insurance companies will send you a letter, fax, or to inform you that you have x number of days to recredential. They will send you a copy of your Uniform Application and you will make any corrections to that form (example: License Expiration Date), provide a copy of your current malpractice insurance face sheet noting limits of coverage and effective and expiration dates of the policy (the provider name will need to be listed on this sheet), and a new copy of your attestation statement. (**See page 20 CAQH Credentialing Data Review and Attestation) Since this entire process is so time consuming, the development of the Council for Affordable Quality Healthcare was developed. At this time, not all insurance companies are participators in this program which makes the previous section necessary. 16

17 Council for Affordable Quality Healthcare What is the Council for Affordable Quality Healthcare? The Council for Affordable Quality Healthcare or CAQH ( developed an online service intended to eliminate the need for multiple insurance credentialing submissions. In short, you complete one form for all of their participating insurance carriers and you authorize who will receive your information. The CAQH Universal Credentialing Datasource is located at: The CAQH has a Universal Provider Datasource which permits providers (the registered dietitian) to enter all the same data required on the paper application into a secure on-line database. This requires the provider (the registered dietitian) to contact the insurance company, to whom they are applying to become credentialed with, who in turn registers the provider (the registered dietitian) with the Council for Affordable Quality Healthcare. The CAQH then issues a registration number and notifies the insurance company who then forwards the identification number to you (the registered dietitian). The provider (the registered dietitian) creates an account with the CAQH s Universal Provider Datasource and completes all the required information on-line. The provider (the registered dietitian) then faxes the necessary licenses, signature pages and insurance facesheets. The CAQH Universal Provider Datasource then distributes this information to participating insurance companies who either approve or deny the application and notify the provider (the registered dietitian) by mail. A list of participating insurance companies with CAQH can be found at: What are the Benefits to participating in a Universal Credentialing Program? Saves time: Filling out multiple forms can take hours, especially when a practice contracts with multiple health plans. CAQH eliminates the need to fill out multiple, redundant and time-consuming forms. Minimizes paperwork: Health plans traditionally require providers to update credentialing information every two or three years. For providers who contract with multiple health plans, this can mean an almost constant stream of paperwork. With CAQH, credentialing and other updates are conveniently fulfilled online in a matter of minutes. Keeps information current Keeping practice information up-to-date isn't just important for credentialing purposes, it's important for health plan records and directories too. With CAQH, a healthcare provider only needs to update information that has changed. There's no need to fill out information forms over and over again. (**See page 21 Attestation Form) And there is not a fee for this service! 17

18 Example: CAQH Application Requirements Healthy Nutrition 18

19 19

20 If you are already credentialed with an insurance company that participates with CAQH, you will need to contact the insurance company and ask them to add CAQH on to your policy. CAQH will then contact you with a CAQH Provider ID Number so that you can create a user name and password to complete your Universal credentialing paperwork. Once you receive your CAQH Provider ID #, you will go to and complete the application process. If you are not credentialed with any insurance companies that participate with CAQH, you will choose the first company that you would like to credential with and when applying, request that they send your information to CAQH. Example: with Blue Cross Blue Shield, you can complete an Online Request to send to CAQH Application Go to the bottom of the page and click Please complete an online request form to obtain a CAQH provider number and they will apply for a CAQH number for you and send you your information. Help Desk & Reference Guide for CAQH The CAQH Provider Help Desk is CAQH Quick Reference Guide is Each time you would like to credential with a new insurance company, you will refer them to CAQH (if they participate). Each time that you apply with a new insurance company through your CAQH, you will update your CAQH application with the Credentialing Data Review and Attestation (**See below). You will also be requested to periodically update your CAQH with updated information such as current professional liability insurance policy information. CAQH Credentialing Data Review and Attestation This is like recredentialing with the insurance companies Anytime there is a need for review, you will receive an notifying you that you should review your information in the Universal Provider Data Source within the next 10 days. If you do not re-attest, many participating insurance companies may be required to contact you directly for credentialing materials. To complete the re-attestation process, please follow these steps: 1. Log onto the Online Application System ( using your Username and Password. 2. Check the Attachments tab to see if any supporting documents (example: proof of professional liability insurance) need to be updated. If so, please be sure to update the appropriate expiration date by going to that section(s), updating the field(s), and click the 'Audit' button at the bottom of page. 3. Go to the Audit tab and select Run Audit. 4. Go to the Attest tab, and follow the quick 3-step attestation process to finalize your updates. 20

21 Example: CAQH Attestation Form (which will also be used for Re-attestation) Each time you complete this process, you will print off a cover sheet and your Attestation Statement (that allows CAQH to share information with each insurance company that you participate with). 21

22 Example: Fax Cover Sheet for CAQH ID# Name Address City, State, Zip Common Attachment IDs that you will use 003 Current Professional Liability Insurance Policy Face Sheet 007 North Carolina State License 016 North Carolina State Release Your initial application will require 014 References 004 W-9 22

23 You will then receive an stating We are pleased to confirm that the reattestation for your application data was successful. Contracting and Provider Relations Provider relations usually consist of specialist, coordinators, contracting, and network management. Each insurance company uses different titles to explain the different positions in their company. If you are individually credentialed with an Insurance Company, you will work closely with a member of the Provider Relations Team to complete your contract. For large organizations, contact your office manager or the billing and reimbursement department in your practice to determine how existing contracts affect your work. At Blue Cross and Blue Shield of NC, Network Management is a health plan manager who is responsible for developing and managing the provider networks including: recruiting, credentialing, contracting, service, and provider performance management. This will be a very important contact person for you. The Network Manager will assist you in completing and answering any questions in regards to your contract, fee schedule for reimbursement, establishing electronic Explanation of Payments (EOP), and ability to receive Electronic Funds Transfers (EFT). This will be discussed further under Filing Insurance Claims. Example with Blue Cross and Blue Shield of North Carolina s Network Management Charlotte: Raleigh: P O Box P.O. Box 2291 Charlotte, NC Durham, NC (704) (fax) (fax) Greensboro: Wilmington/Greenville: 2303 West Meadowview Road, Suite 200 P.O. Box 2291 Greensboro, NC Durham, NC Wilmington: (336) (fax) Greenville: Hickory: (919) (fax) P.O. Box 2291 Durham, NC application/contacts.htm (fax) 23

24 Example: Medicaid s Provider Service Representatives for Physicians Including the following providers: Health-related svcs in Ambulatory sx Eye care public schools Nurse midwife Anesthesiology Head Start Independent dx testing facility Nurse practitioner Chiropractor Health Check Independent mental health provider Physician Certified RN anesthetist Health department Independent practitioner program Planned Parenthood AREA I AREA II AREA III AREA IV Travel Representative: Travel Representative: Travel Representative: Travel Representative: Ashe Anson Alamance Beaufort Alexander Bladen Caswell Bertie Alleghany Cabarrus Chatham Brunswick Avery Columbus Durham Camden Buncombe Cumberland Franklin Carteret Burke Davidson Granville Chowan Caldwell Davie Guilford Craven Catawba Forsyth Halifax Currituck Cherokee Hoke Harnett Dare Clay Mecklenburg Lee Duplin Cleveland Montgomery Moore Edgecombe Gaston Richmond Northampton Gates Graham Robeson Orange Greene Haywood Rowan Person Hertford Henderson Scotland Randolph Hyde Iredell Stanly Rockingham Johnston Jackson Stokes Vance Jones Lincoln Surry Warren Lenoir Macon Union Martin Madison Yadkin Nash McDowell Mitchell Polk Rutherford Swain Transylvania Watauga Wilkes Yancey Contact Information: or New Hanover Onslow Pamlico Pasquotank Pender Perquimans Pitt Sampson Tyrrell Washington Wake Wayne Wilson 24

25 Employer Identification Number (You will need this only if you are in a private setting) What is an Employer Identification Number (EIN)? An Employer Identification Number (EIN) is a nine-digit number that the IRS assigns in the following format: XX-XXXXXXX. It is used to identify the tax accounts of employers and certain others who have no employees. The IRS uses the number to identify taxpayers that are required to file various business tax returns. There is detailed information available at the IRS website. It is also recommended that you speak with your accountant or business advisor regarding what form of business entity to establish. Your form of business determines which income tax return form you have to file. How do you know if you need an EIN? Any person (or entity) that files taxes needs an identification number of some kind. It's how the IRS tracks who's paying what to where and when. When you work for someone else, your social security number is used. If you are going to employ workers, you are generally required to withhold, deposit and report employment taxes. To file the various tax returns, including employment tax returns, you need an Employer Identification Number (EIN). However, a sole proprietor may use his or her social security number in lieu of an EIN if the business has no employees and is not required to file excise, employment, alcohol, tobacco, or firearms returns. A sole proprietorship is the only type of business that may use a social security number rather than an EIN. If you are a sole proprietor you can still have a business name. You can either name your business Jane Doe, Dietitian or Jane Doe, doing business as (dba) Nutrition Success. Reasons to remain a sole proprietor (self-employed) under your Social Security Number The first advantage is avoidance of double tax. What is double tax? Corporations pay income tax separately from their owners. Double tax can occur when you (through your personal tax return) and your business (through its corporate tax return) must both pay taxes on the same dollar of income. (Example*: If your Gross Salary is $35,999.98, as an employee, you might pay $ on personal taxes withheld [as you would with an employer] AND $ taxes AS the employer. If you are self-employed, you will still have to pay self-employment taxes, which is generally a higher tax rate than your personal taxes withheld, but not as large of a percentage of your cash flow is being paid out. * These tax rates have many variables and this is a just one example. Consult your tax advisor or IRS website for additional tax/accounting information. The second tax advantage of sole proprietorships is that you can deduct your business losses to the extent of your total income that you may have from all sources, including interest, dividends, and gains from the sale of non-business property. Furthermore, if you are married and file a joint tax return, your business losses will also offset your spouse's income. 25

26 Reasons to explore other business entities available to you: The principal disadvantage of sole proprietorships is that you, the sole proprietor, are personally liable for all the debts of your sole proprietorship. (Example: Say a patient sues you. Your patient can look to all of your personal and business assets including your bank accounts, vehicles, equipment, and perhaps even your house!) A second disadvantage of conducting business as a sole proprietorship is that you may pay higher income taxes. As a sole proprietor, you report your business income on your personal tax return. While you do avoid double tax this way, if as a single person your total adjusted gross income exceeds $115,000, or as a married person filing jointly your adjusted gross income exceeds $140,000, you may pay income tax at the highest rate. By incorporating your business, you may be able to reduce your tax rate. Additional details on business entity types to consider when setting up an RD private practice can be found on the IRS web page, in general business textbooks, from local business association groups, or an accountant. Where/How do you get an EIN? There are four ways to apply for an EIN: The Internet EIN application is the preferred method for customers to apply for and obtain an EIN. Once the application is completed, the information is validated during the online session, and an EIN is issued immediately. The online application process is available for all entities whose principal business, office, or agency, or legal residence (in the case of an individual) is located in the United States or U.S. Territories. The principal officer, general partner, grantor, owner, trustee, etc. must have a valid Taxpayer Identification Number (Social Security Number, Employer Identification Number, or Individual Taxpayer Identification number) in order to use the online application. Go to You may obtain an EIN immediately by telephone 5 days a week, Monday through Friday from 7:00 a.m. to 10:00 p.m. (local time), by calling IRS at You may use this EIN immediately to file a paper return or make a payment of tax. You may obtain an EIN by completing Form SS-4 (PDF), Application for Employer Identification Number, and faxing it to the IRS for processing. The IRS Fax numbers are provided in the Form SS-4 Instructions. An EIN applied for by fax will be issued within 4 business days. You may also obtain an EIN by completing the Form SS-4 and mailing it to the IRS service center address listed on the Form SS-4 Instructions. By mailing the completed Form SS-4 to the appropriate service center, you can obtain an EIN within 4 to 5 weeks. 26

27 Professional Liability Insurance No matter how careful you perform your job, the activities you are involved in on a daily basis can put your career and financial stability on the line. Whether you re employed, selfemployed, work full time or part time, or are a student practicing under supervision, having your own professional liability coverage is an important service to purchase for your business. Most, if not all, health plans require professional liability insurance for practitioners whom the plan credentials as network providers. If you work for a large organization or office, contact your office manager or legal department to determine what coverage is provided for you. You may opt to have additional coverage. Professional liability insurance is available through several vendors. ADA membership allows members an opportunity to receive affordable group rates on professional liability insurance. (The direct link for Marsh is There is an annual cost for this policy which varies based on if you are employed, self employed, or student, the number of hours you work, and your specific coverage. The cost is generally less than $150/year. Additional coverage for property and employees can also be added to the RD s professional liability plan. W-9 Form (Request for Taxpayer Identification Number and Certification) A Form W-9 is a document issued by the United States Internal Revenue Service (IRS) for certain taxation purposes. While W-9's aren't filed with the IRS, they are collected by the insurance companies that hire independent contractors. This form and instructions can be located at You will need to complete a copy of this form for CAQH or each of the insurance companies you credential with. Completing the W-9 Form If your NPI that you are using was established as an individual using your Social Security Number, you will list your Individual name as shown on your income tax return on the Name line and your address. You may also enter your business, trade, or doing business as (DBA) name on the Business name line. If your NPI that you are using was established as an organization using an Employer Identification Number, you will list your Business name as shown on your income tax return on the Name line. Part I Taxpayer Identification Number (TIN) If your NPI that you are using was established as an individual using your Social Security Number (SSN), you will provide your SSN on this line of the W-9 Form. If your NPI that you are using was established as an organization using an Employer Identification Number (EIN), you will provide your EIN on this line of the W-9 Form. Part II Certification Read and sign 27

28 III. Insurers and Coverage, Procedure Codes, and Diagnosis Codes Insurers and Coverage There are not any two insurance companies that have the exact same policy. And within any company, two policies can also be totally different. This section focuses only on the patient s MNT benefits. We will be discussing procedure codes and diagnosis codes in the sections to follow. If you are a private practice registered dietitian doing your own billing, you need to understand the intricacies of the policies to ensure you receive compensation for your work. If you work for a large medical organization, the individual in charge of billing and reimbursement may understand the intricacies of billing for physician and laboratory services, but may have no experience in billing for medical nutrition therapy. It may be necessary for you to provide information, such as that included in this manual, to those individuals. Each section to follow will review a number of details for each policy type. Examples of Insurance Cards that represent the type of policy being reviewed Credential & Reimburse Registered Dietitians Some policies credential and reimburse registered dietitians individually. Some policies do not credential registered dietitians but will reimburse for MNT with a Registered Dietitian. Some policies do not credential registered dietitians, but will reimburse if the MNT services are provided Incident to a Physician s Visit. Incident to services are defined as services that are an integral, although incidental, part of the physician's professional service which is commonly rendered without charge or included in the physician's bill and are commonly furnished in physician's offices or clinics and either furnished by the physician or by auxiliary personnel under the physician's supervision. Referral needed Some policies require that you have a physician s referral for a nutritional consult (written, telephone, etc). Some policies require that you have a written referral to a HMO provider. Special Requirements Some policies only reimburse for patients who are enrolled in specific programs (example: Member Health Partnerships with BCBSNC), are a particular age, or have a particular diagnosis code. 28

29 Benefits for the patient o Deductible The specified dollar amount for certain covered services that the member must incur before benefits are payable for the remaining covered services. The deductible does not include copayments, member coinsurance, charge in excess of the allowed amount, amounts exceeding any maximum and expenses for non-covered services. o Copayment (copay) - The fixed-dollar amount which is due and payable by the member at the time a covered service is provided. (Example $25) o Coinsurance - The sharing of charges by the insurance company and the patient for covered services received, usually stated as a percentage of the allowed amount after the deductible has been satisfied. (Example Insurer pays 80% - Members Coinsurance is 20%). Some policies have a Coinsurance Maximum - The maximum amount of coinsurance that the patient is obligated to pay for covered services per calendar year/benefit period. o Limit of visits Some policies have a limit to the number of visits covered under the policy, yet some policies have different coverage criteria for different diagnosis. Some policies may only limit the number of units (see below). o Limit Units Some policies have a limit to the number of units covered under the policy. (**See page 71 Units) o Out-of-Network benefits An In-network Provider has been designated as a provider by becoming credentialed and contracted with the particular insurance company. An Out-of-Network Provider has not been credentialed or signed a contract with the particular insurance company. In most instances members will incur a higher out-of-pocket expense for utilizing out-of-network providers. However, some benefit plans types will not cover services rendered by an out-of-network provider. This is usually the case for traditional HMO plans. o Exceptions Some independent or employer-based policies will carve out specific benefits available to their employees which are the separation of a medical service (or a group of services) from the basic set of benefits in some way whether they do not cover that particular benefit or they limit coverage in some way. (Example: Some policies do not participate in BCBSNC s Member Health Partnership Program) 29

30 Blue Cross and Blue Shield NC Blue Options, Blue Advantage, & Blue Care Credential & Reimburse Registered Dietitians Yes Referral needed Not Required Special Requirements Member must be enrolled in the Health Partnership Program or have a diagnosis of diabetes Benefits for the patient o Deductible None in-network o Copay/Coinsurance None in network for first 6 visits per benefit period and if the diagnosis is DM, copay/coinsurance and deductible applies after the first 6 visits o Limit of visits 6 visits per year with enrollment into the Member Health Partnership Program (All medically necessary diagnoses are covered including V65.3 which can be used if the patient is not obese and has no other health conditions but would like to learn about a healthy, well-balanced diet.) Unlimited with the diagnosis of Diabetes (copay or coinsurance and deductible applies) o Limit Units No unit limit per visit or per year o Out-of-Network benefits Deductible and co-insurance apply 30

31 NOTES: For assistance with BCBSNC Benefits call To enroll a patient in the Member Health Partnership Program They will need to call Press 1 (for English) and Press 1 again (for MHP Survey) They will need their subscriber ID #, name, and date of birth They will then take a short survey The patient will only need to enroll once per lifetime to receive this benefit every year Members can also enroll through the website at bcbsnc.com, or by sending an to [email protected]. To verify patient enrollment in the Member Health Partnership Program You will need to call Press 1 (for English) and Press 2 (to verify MHP benefits) You will need your Provider ID # or NPI # They will need their subscriber ID #, name, and date of birth You will then note for your records: the date, the name of the person you spoke with, and the patient s date of enrollment in the program. 31

32 Blue Cross and Blue Shield NC Employer-Based Plans Employer-Based programs are policies that may have carved out benefits or have special criteria for their employees. The plans are identified by the card (ex. Blue Options, Blue Options PPO with no Out-of-Network Benefits, etc.), but the Subscriber ID is sometimes different than the standard policies sampled above and are sometimes more specific for that company plan. Please note that some self-insured employer groups may choose to omit medical nutrition therapy from coverage for their employees. For this reason, it is always a good idea to verify a member s eligibility before the member s first visit. Plans offered through Duke University to their employees are an example of the variety of policies that are available by an employer. Duke Select Credential & Reimburse Registered Dietitians No/Yes Referral needed Not Required Special Requirements None Benefits for the patient o Deductible None in-network 32

33 o Copay/Coinsurance $15 per visit o Limit of visits 6 visits per year o Limit Units No unit limit per visit or per year o Out-of-Network benefits -No current information available- o Exceptions -No current information available- Duke Basic billed through Blue Cross and Blue Shield HMO Credential & Reimburse Registered Dietitians No/Yes Referral needed Not Required Special Requirements None Benefits for the patient o Deductible None in-network o Copay/Coinsurance $20 per visit o Limit of visits 6 visits per year o Limit Units No unit limit per visit or per year o Out-of-Network benefits No benefit o Exceptions None Blue Care billed through Blue Cross and Blue Shield HMO Credential & Reimburse Registered Dietitians Yes Referral needed Not Required Special Requirements Enroll Member Health Partnership Program 33

34 Benefits for the patient o Deductible None in-network o Copay/Coinsurance None in-network o Limit of visits 6 visits per year o Limit Units No unit limit per visit or per year o Out-of-Network benefits -No current information available- o Exceptions -No current information available- Duke Options billed through Blue Cross and Blue Shield PPO Credential & Reimburse Registered Dietitians Yes Referral needed Not Required Special Requirements Enroll Member Health Partnership Program Benefits for the patient o Deductible None in-network o Copay/Coinsurance None in-network o Limit of visits 6 visits per year o Limit Units No unit limit per visit or per year o Out-of-Network benefits Yes, but deductible and copay/coinsurance is applied o Exceptions -No current information available- NOTES: For assistance with Duke Benefits Call

35 Blue Cross and Blue Shield NC HSA (Health Savings Account) or HRA (Health Reimbursement Accounts/Arrangements) These are consumer-driven health plans (CDHP) designed to return control of healthcare dollars to the people who use them - consumers. CDHPs encourage members to help control costs by becoming more directly involved in the selection and purchase of healthcare services. Members can use funds in their consumer spending accounts at their discretion to pay for healthcare. Access to benefit and account information, health management programs and resources, and additional support helps them manage their expenses. With the HSA and HRA, the patient would pay a large deductible up front and then their insurance would pay their benefits. With HSA, there is no co-insurance and with HRA, there is after the deductible has been met. Benefits are not part of the first dollar preventive care and subject to deductible and coinsurance. Credential & Reimburse Registered Dietitians Yes Referral needed Not Required Special Requirements Enroll Member Health Partnership Program or DM diagnosis and meet deductible 35

36 Benefits for the patient o Deductible Varies by policy. See member ID card o Copay/Coinsurance Due to Federal regulations, deductible and co-insurance applies for HSA and HRA policies o Limit of visits 6 visits per year with enrollment into the Member Health Partnership Program (All medically necessary diagnoses are covered including V65.3 which can be used if the patient is not obese and has no other health conditions but would like to learn about a healthy, well-balanced diet.) 6 visits per year with the diagnosis of Diabetes and with medical necessity after o Limit Units No unit limit per visit or per year o Out-of-Network benefits Deductible and co-insurance o Exceptions if the employer has a carved these benefits out of the policy, it will not be covered if there is a pre-existing clause in the policy with any diagnosis, it will not be covered Consumer Directed Health Care and Health Care Debit Cards BlueCard eligible members from another Blue Plan s service area who have CDHC plans often carry health care debit cards that allow them to pay for out-of-pocket costs using funds from their Health Reimbursement Account (HRA), Health Savings Account (HSA) or Flexible Spending Account (FSA). Some cards are stand-alone debit cards that cover eligible out-ofpocket costs, while others also serve as a health plan member ID card. Members can use their cards to pay outstanding balances on billing statements. They can also use their cards via phone in order to process payments. 36

37 Blue Cross and Blue Shield NC Classic Blue - This is a comprehensive major medical plan. Medical nutrition therapy is not covered 37

38 Blue Cross and Blue Shield NC - State Health Plan PPO Credential & Reimburse Registered Dietitians Yes Referral needed Not Required Special Requirements None Benefits for the patient o Deductible Basic PPO - None in-network for the first 6 visits with a diagnosis of diabetes and then $600 for Standard Plans or $800 for Basic Plans after 6 th visit with a diagnosis of diabetes Standard PPO - None in-network for the 4 covered visits with all medically necessary diagnoses o Copay/Coinsurance Basic PPO Coinsurance - None in-network for first 6 visits with diabetes. After 6 th visit, 30% Coinsurance after deductible is met Standard PPO Coinsurance - None in-network for first 6 visits with diabetes. After 6 th visit, 20% Coinsurance after deductible is met Basic PPO Copay- Copayment listed on patient s card for all other conditions with a medically necessary diagnosis for 4 annual visits Standard PPO Copay - Copayment listed on patient s card for all other conditions with a medically necessary diagnosis for 4 annual visits 38

39 o Limit of visits 6 visits per year with the diagnosis of diabetes and with medical necessity after 4 visits per year for conditions other than Diabetes, with all other medically necessary diagnoses o Limit Units No unit limit per visit or per year o Out-of-Network benefits Basic PPO Deductible - $1600 & Basic PPO Coinsurance - 50% Standard PPO Plan Deductible - $ & Standard PPO Plan 40% Limit of visits apply to conditions other than Diabetes o Exceptions -No current information available- NOTES: For assistance with BCBS State Health Plan Benefits State PPO You will then note for your records: the date, the name of the person you spoke with, and a reference number for today s call. You may need this if there is any question regarding reimbursement for this patient. 39

40 Blue Cross and Blue Shield NC Federal Standard Policy Credential & Reimburse Registered Dietitians Yes Referral needed Not Required Special Requirements None Benefits for the patient o Deductible $300 deductible o Copay/Coinsurance 15% coinsurance o Limit of visits 6 visits per year with all medically necessary diagnoses except obesity Unlimited visits for anorexia, bulimia, and eating disorders if member is in a treatment plan. No member copayment or deductible for first 6 visits, subsequent visits subject to deductible. o Limit Units No unit limit per visit or per year o Out-of-Network benefits Reimbursed at 75% of the plan allowance after the deductible. The member is also responsible for any difference between the allowed amount and the billed amount, up to 6 visits per calendar year. o Exceptions This policy does not cover obesity (Diagnosis code 278.xx) NOTES: For assistance with Federal Blue Cross and Blue Shield Benefits Federal You will then note for your records: the date, the name of the person you spoke with, and a reference number for today s call. You may need this if there is any question regarding reimbursement for this patient. 40

41 Blue Cross and Blue Shield NC Federal Basic Policy Credential & Reimburse Registered Dietitians Yes Referral needed Not Required Special Requirements None Benefits for the patient o Deductible $0 o Copay/Coinsurance $25 copay o Limit of visits 6 visits per year with all medically necessary diagnoses except obesity Unlimited visits for anorexia, bulimia, and eating disorders if member is in a treatment plan. No member copayment or deductible for first 6 visits, subsequent visits subject to deductible. o Limit Units No unit limit per visit or per year o Out-of-Network benefits None o Exceptions This policy does not cover obesity (Diagnosis code 278.xx) NOTES: For assistance with Federal Blue Cross and Blue Shield Benefits Federal You will then note for your records: the date, the name of the person you spoke with, and a reference number for today s call. You may need this if there is any question regarding reimbursement for this patient. 41

42 Blue Cross and Blue Shield NC Standard and Basic Policy Jump 4 Health Weight Management Program Credential & Reimburse Registered Dietitians Yes Referral needed Not Required Special Requirements Children age 5 through 17 whose Body Mass Index (BMI) falls in the 85th percentile or higher, according to standards established by the Centers for Disease Control and Prevention (CDC) may be eligible to participate in our new Jump 4 Health Weight Management Program. The child must enroll in the Jump 4 Health Program, and then simply calculate and submit his or her BMI through our Web site, Go to fepblue.org > MyBlue > MyBlue Personal Health Record > Healthy Families > Register now Benefits for the patient o Deductible $0 o Copay/Coinsurance See above policy information If the child meets the criteria for participation, we will provide him or her with a program certificate. The certificate will entitle the child to receive up to 4 nutritional counseling visits per year at no charge and the copay/coinsurance will apply for the remaining. o Limit of visits 6 visits per year with all medically necessary diagnoses o Limit Units None o Out- of- Network benefits None o Exceptions None 42

43 Example: Nutrition Counseling Certificate 43

44 Blue Cross and Blue Shield Out of State All out-of-state Blue Plan members who are enrolled in a benefit plan and eligible as part of the BlueCard program will have an alpha prefix included as part of their member identification number (member identification numbers for BlueCard eligible members include a combination of both alpha and numeric characters). A correct member ID number includes an alpha prefix in the first three positions, followed by a combination of alpha and/or numeric characters. The combination of alpha and numeric characters can vary among the amount of letters and numbers used to comprise a member s ID and can be up to 17 character positions in total. This means that you may see cards with ID numbers between six and 14 (numeric/alpha) characters in length, in addition to the alpha prefix (3-letter alpha prefix additional characters = 9-17 characters in total, depending on the ID given to a specific member). Credential & Reimburse Registered Dietitians Yes, when you credential as a local PPO provider with your local Blue Cross, it will cover all Blue Cross policies in and out of state. Referral needed May Be Required by some policies Special Requirements Varies per policy Benefits for the patient o Deductible Varies per policy o Copay/Coinsurance Varies per policy o Limit of visits Varies per policy 44

45 o Limit Units Varies per policy o Out-of-Network benefits Varies per policy o Exceptions Varies per policy NOTES: For assistance with Out-of-State Blue Cross Benefits You can either dial the number for Provider Services located on the patient s insurance card or Call and ext 4 You will then note for your records: the date, the name of the person you spoke with, and a reference number for today s call. You may need this if there is any question regarding reimbursement for this patient. Example: Policies vary per state, per individual policy, deductibles, copays/coinsurance, diagnoses covered, and visit limits. It is important that you check each policy individually. A policy that begins with FMC is a policy from BCBS Massachusetts - Paid all but $35.00 copay with diagnosis code A policy that begins with BSH is a policy from Anthem Blue Cross of California - Paid all but 10% copay with diagnosis code A policy that begins with KCB is a policy from BCBS Rhode Island- Paid all but $35.00 copay with any medical diagnosis A policy that begins with MWQ is a policy from Anthem Blue Cross Blue Shield of Virginia - Paid all but $40.00 copay with diagnosis code visits / lifetime. 45

46 Health Choice Plan Credential & Reimburse Registered Dietitians No Referral needed No, but is limited to Medically Supervised Facility that meets the standards of the National Diabetes Advisory Board Special Requirements No Benefits for the patient o Deductible $0 o Copay/Coinsurance $5 copay listed on front of card if there is one or $0 o Limit of visits None, see exceptions o Limit Units None, see exceptions o Out-of-Network benefits None o Exceptions $300 / plan year o Notes Reimbursement is at 100% of the Medicaid Reimbursement Rate **Many dietitians have reported difficulty being reimbursed for nutrition therapy with the single diagnosis of obesity without any other co-morbidities. NOTES: For assistance with Health Choice Plan Benefits You will then note for your records: the date, the name of the person you spoke with, and a reference number for today s call. You may need this if there is any question regarding reimbursement for this patient. 46

47 The referring physician is required to fill out a one page form declaring the patient has a chronic medical condition as well. Example: Physician Certification 47

48 Medicaid Credential & Reimburse Registered Dietitians No Providers Eligible to Bill for the Procedure, Product, or Service To be eligible to bill for procedures, products, and services related to this policy, providers shall meet Medicaid s qualifications for participation; be currently enrolled with N.C. Medicaid; and bill only for procedures, products, and services that are within the scope of their clinical practice, as defined by the appropriate licensing entity. Medicaid-enrolled providers who employ or contract with licensed dietitians/nutritionists or registered dietitians (for example, local health departments, rural health centers, federally qualified health centers, physician or medical diagnostic clinics, outpatient hospitals and physicians) are eligible to bill for this service. Provider Qualifications Dietary evaluation and counseling provided in public agencies, private agencies, clinics, physician or Medical diagnostic clinics, and physician offices shall be performed by a. a dietitian/nutritionist, currently licensed by the N.C. Board of Dietetics/Nutrition (provisional license is not acceptable); OR b. a registered dietitian, currently registered with the Commission of Dietetic Registration (registration eligibility is not acceptable). 48

49 Staff Qualifications It is the responsibility of the provider agency to verify in writing all staff qualifications for their staff s provision of service. A copy of this verification (current licensure or registration) shall be maintained by the provider agency. Referral needed For services other than the Primary Care Physician s (PCPs) office, the PCP must provide a referral before going to any specialty office that may employ or contract with a dietitian. Special Requirements Children through 20 Years of Age are eligible for dietary evaluation and counseling when they meet the medical necessity criteria. Medicaid covers dietary evaluation and counseling for children through 20 years of age when there is a chronic, episodic, or acute condition for which nutrition therapy is a critical component of medical management, including but not limited to the following: a. Inappropriate growth/weight gain such as inadequate weight gain, inappropriate weight loss, underweight, obesity, inadequate linear growth, or short stature b. Nutritional anemia c. Eating or feeding disorders that result in a medical condition such as failure to thrive, anorexia nervosa, or bulimia nervosa d. Physical conditions that have an impact on growth and feeding, such as very low birth weight, necrotizing enterocolitis, cleft palate, cerebral palsy, and neural tube defects e. Chronic or prolonged infections that have a nutritional treatment component, such as HIV or hepatitis f. Genetic conditions that affect growth and feeding, such as cystic fibrosis, Prader- Willi Syndrome, or Down Syndrome g. Chronic medical conditions, such as cancer, chronic or congenital cardiac disease, hypertension, hyperlipidemia, gastrointestinal diseases, liver disease, pulmonary disease, malabsorption syndromes, renal disease, significant food allergies, and diseases of the immune system h. Metabolic disorders such as inborn errors of metabolism (PKU, galactosemia, etc.) and endocrine disorders (diabetes, etc.) i. Non-healing wounds due to chronic conditions j. Acute burns over significant body surface area k. Metabolic Syndrome/Type 2 diabetes l. Documented history of a relative of the first degree with cardiovascular disease and/or possessing factors that significantly increase the risk of cardiovascular disease, such as a sedentary lifestyle, elevated cholesterol, smoking, high blood pressure, and higher than ideal body weight 49

50 Pregnant and Postpartum Women threatened by chronic, episodic, or acute conditions for which nutrition therapy is a critical component of medical management, and for postpartum women who need follow-up for these conditions or who develop such conditions early in the postpartum period, including but not limited to the following: a. Conditions that affect the length of gestation or the birth weight, where nutrition is an underlying cause, such as 1. Severe anemia (HGB < 10M/DL or HCT < 30) 2. Pre-conceptionally underweight (<90% standard weight for height) 3. Inadequate weight gain during pregnancy 4. Intrauterine growth retardation 5. Very young maternal age (under the age of 16) 6. Multiple gestation 7. Substance abuse b. Metabolic disorders, such as diabetes, thyroid dysfunction, maternal PKU, or other inborn errors of metabolism c. Chronic medical conditions, such as cancer, heart disease, hypertension, hyperlipidemia, inflammatory bowel disease, malabsorption syndromes, or renal disease d. Auto-immune diseases of nutritional significance, such as systemic lupus erythematosus e. Eating disorders, such as severe pica, anorexia nervosa, or bulimia nervosa f. Obesity when the following criteria are met: 1. BMI > 30 in same woman pre-pregnancy and post partum 2. BMI > 35 at 6 weeks of pregnancy 3. BMI > 30 at 12 weeks of pregnancy g. Documented history of a relative of the first degree with cardiovascular disease and/or possessing factors that significantly increase the risk of cardiovascular disease, such as a sedentary lifestyle, elevated cholesterol, smoking, high blood pressure, and higher than ideal body weight 50

51 One of the primary diagnosis codes listed below must be used when the pregnant or postpartum recipient is 21 years of age or older. Normal pregnancy; supervision of normal first pregnancy V22.0 Normal pregnancy; supervision of other normal pregnancy V22.1 Normal pregnancy; pregnant state, incidental V22.2 Supervision of high-risk pregnancy; pregnancy with history of infertility V23.0 Supervision of high-risk pregnancy; pregnancy with history of trophoblastic disease V23.1 Supervision of high-risk pregnancy; pregnancy with history of abortion V23.2 Supervision of high-risk pregnancy; grand multiparity V23.3 Supervision of high-risk pregnancy; pregnancy with other poor obstetric history V23.4 Supervision of high-risk pregnancy; pregnancy with other poor reproductive history V23.5 Supervision of high-risk pregnancy; insufficient prenatal care V23.7 Other high-risk pregnancy; elderly primigravida V23.81 Other high-risk pregnancy; elderly multigravida V23.82 Other high-risk pregnancy; young primigravida V23.83 Other high-risk pregnancy; young multigravida V23.84 Other high-risk pregnancy V23.89 Unspecified high-risk pregnancy V23.9 Postpartum care and examination; routine postpartum follow-up V24.2 Overweight and obesity; obesity, unspecified Overweight and obesity; morbid obesity Lack of expected normal physiological development in childhood; failure to thrive Adult failure to thrive All Other Patients will be seen for Medical Necessity as directed by the Physician. Benefits for the patient Dietary evaluation and counseling must be provided as an individual, face-to-face encounter with the recipient or the recipient s caretaker. o Deductible If a household s income exceeds the allowable level, the applicant may be eligible for Medicaid after sufficient medical expenses are incurred to meet a deductible. The deductible is calculated using a formula set by law. You must check recipient eligibility by calling or if you have a logon and user name for Electronic Claims Submission or you must complete a Provider Form at and call or option 1 to enroll to get logon information. o Copay/Coinsurance Providers may bill the patient for the applicable copayment amount, but may not refuse services for inability to pay copayment. DO NOT ENTER COPAYMENT AS A PRIOR PAYMENT ON THE CLAIM FORM. The copayment is deducted automatically when the claim is processed. 51

52 Physician s Visit $3.00 per visit The following copayments apply to all Medicaid recipients except those specifically exempted by law from copayment as follows: Services provided to CAP participants Services related to pregnancy Services to individuals under the age of 21 There are further exemptions available at but are not related to normal physician office visits. Services covered by both Medicare and Medicaid are not subject to a Medicaid copayment. However, if Medicare denies the service and the provider submits the claim to Medicaid, the recipient may be responsible for the appropriate Medicaid copayment. o Limit of visits See also limit of units Recipients Who Are Not Subject to the Annual Visit Limitation The following recipients are exempt from the annual visit limitation. 1. Recipients under the age of Recipients enrolled in a Community Alternatives Program (CAP) 3. Pregnant recipients who are receiving prenatal and pregnancy-related services Mandatory Services Annual Visit Limit Period - July 1 through June 30 Number of Visits - 22 Provider Types Included in Visit Count: Physicians (except for physicians enrolled in N.C. Medicaid with a specialty of oncology, radiology, or nuclear medicine) Nurse practitioners Nurse midwives Health departments Rural health clinics Federally qualified health centers Optional Services Annual Visit Limit Period - July 1 through June 30 Number of Visits - 8 Provider Types Included in Visit Count: Chiropractors Optometrists Podiatrists According to the Centers for Medicare and Medicaid Services (CMS), a visit limit may not combine both mandatory and optional services. 52

53 o Limit Units Initial Assessment - Service is limited to a maximum of 4 units per date of service and cannot exceed 4 units per 270 days. Re-assessment - Service is limited to a maximum of 4 units per date of service and cannot exceed a maximum of 20 units per 365 days. o Out-of-Network benefits None o Notes - Billing Providers may not bill a recipient for the difference between the provider s charges and the Medicaid payment in addition to copayment and third-party payment. any service covered by the Medicaid program unless the provider has specifically informed the recipient that Medicaid will not be billed, and the recipient understands and agrees to accept liability for payment. any service covered by the Medicaid program for which the provider is denied payment because the provider failed to follow program regulations including, but not limited to, errors on claims, late submission, lack of prior approval, failure to bill third-party resources, etc. When a non-covered service is requested by a recipient, the provider must inform the recipient either orally or in writing that the requested service is not covered under the Medicaid program and will, therefore, be the financial responsibility of the recipient. This must be done prior to rendering the service. NOTES: For assistance with Medicaid Benefits Contact Information: or Benefits - Schedule of Fees

54 CPT or Procedure Codes CPT (Current Procedural Terminology) or procedure codes are numbers assigned to every task and service a medical practitioner may provide to a patient. They are then used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer. This code set is maintained and copyrighted by the American Medical Association (AMA), and adopted by the Secretary of Health and Human Services as the standard for reporting physician and other services on standard transactions. These are typical billing codes accepted by most insurance companies. Medicaid reimburses for and A variety of payers require RDs to use the MNT CPT codes for nutrition services covered by the plan. Check payer policies to verify CPT codes to use on claims Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minute unit. (**See page 71 Units) Re-assessment and intervention, individual, face-to-face with the patient, each 15 minute unit. (**See page 71 Units) Group [2 or more individual(s)], each 30 minute unit. (**See page 71 Units) You will bill for the number of units that you are face-to-face with the patient. S9465 S9470 Diabetic management program, per dietitian visit Nutritional counseling, per dietitian visit CPT codes, descriptions and material only are copyright 2009 American Medical Association. All rights reserved. Determining units of MNT codes to report on claims RDs should report the number of units based on the time that you interact and provide services to the patient. (**See page 71 Units) Example: If you met with Patient A for 1 ½ hour for an initial consult, you would use procedure code x 6 units. If you met with Patient B for a 30 minute group session, you would use procedure code x 1 unit. 54

55 ICD-9-CM or Diagnosis Codes The International Classification of Diseases, Clinical Modification (ICD-9-CM) is a classification used in assigning codes to diagnoses associated with inpatient, outpatient, and physician office utilization in the U.S. Under this system, every health condition can be assigned to a unique category and given a code, up to six characters long. When filing claims, you will need to check the insurance policy to determine if coverage is available for the specific disease or condition (ICD code) for nutrition services. Although RDs have been advised that it is out of their scope of practice to determine a client s medical diagnosis, reporting a diagnosis code on a claim, based on information provided by a physician or health care team, is a normal business practice. If physician information, such as the medical diagnosis, is not available, RDs should use the best available information to determine the diagnosis code to list on the claims form in accordance with payer claims processing policies. The use of a medical diagnosis code on a claim does not constitute a medical diagnosis by an RD for legal purposes; however, RDs should check with providers to see if a policy exists for reporting the medical diagnosis on a claim when a physician- derived diagnosis is unavailable. (1) (1) Referral Systems in Ambulatory Care Providing Access to the Nutrition Care Process, Kren K. et. al., Journal of the American Dietetic Association. August 2008 (Vol. 108, Issue 8, Pages ). ICD-10-CM The government and private health plans are converting from the ICD-9-CM diagnosis code data set to ICD-10-CM. The compliance date for implementation of the International Classification of Diseases, 10th Edition, Clinical Modification/Procedure Coding System (ICD- 10-CM/PCS) is October 1, 2013 for all covered entities. For further information on ICD-10- CM, go to Example: Blue Cross and Blue Shield Federal will cover any ICD code that shows medical necessity for Nutrition Therapy at 100% after their deductible and co-pay/co-insurance except the ICD code Morbid Obesity. Blue Cross and Blue Shield State Health Plan will cover the ICD code 250.xx Diabetes for Nutrition Therapy at 100% for 6 visits each year, but will only cover 4 visits with a $25 copay for any other ICD code if it is medical necessary Nutrition Therapy. 55

56 Common ICD-9-CM codes are: Abnormal Weight Gain Anorexia / Loss of Appetite Celiac Disease Chronic Kidney Disease Congestive Heart Failure Diabetes Mellitus (Insulin Dependent) Diabetes Mellitus (Non-Insulin Dependent) or unspecified without mention of complication Dietary surveillance and counseling V65.3 Diverticulitis of colon (without hemorrhage) Dysphagia End Stage Renal Disease Esophageal reflux Failure to Thrive Child (Lack of expected normal physiological development in childhood) Fibromyalgia Hypercholesterolemia Hyperlipidemia Hypertension - Unspecified Hypoglycemia Hypothyroid Inappropriate diet and eating habits V69.1 Insulin Resistance Irritable Bowel Syndrome Loss of Weight Malnutrition of moderate degree 263 Metabolic Syndrome Nausea and vomiting Nutritional marasmus 261 Obesity Obesity - Morbid Osteoporosis Pernicious Anemia Polycystic Ovarian Syndrome Pre-op Examination V72.84 Protein-calorie malnutrition Severe 262 Sleep apnea-unspecified Source: International Classification of Diseases 9 th Revision, Clinical Modification, ICD-9-CM 2010 for Physicians, Volumes I & II, copyright 2009, Contexo Media. (Note, diagnosis codes are updated at least annually, check payer policies and/or with the referring physician to verify correct diagnosis code.) Nutritional counseling for the treatment of anorexia or bulimia may not be eligible for benefits when provided by registered dietitians. Check payer policy. Complex eating disorders are primarily considered part of a member s mental health benefit. 56

57 IV. Verifying Insurance Coverage and Benefits Information Needed for Verifying Patient Coverage When patients are referred by a physician or call for an appointment, important information that you will need to request from the provider or patient is listed below. A standard referral page or intake of information is often helpful in collecting the needed information. (**See page 60 Sample Referral Page) Patient s Name (as it appears on their insurance card) Patient s Date of Birth Patient s Insurance Company Patient s Insurance Company s Provider Telephone Number Patient s Policy Number o If this is the only insurance that the patient has, follow to the next question. o If the patient has more than one insurance company, obtain the above information for each policy. o You will need to file with the patient s primary insurance policy first. If you are not credentialed with the primary insurance company, you will have no way to file that policy and therefore will not get a primary denial and will not be able to file the secondary insurance. (**See page 76 Filing Primary and Secondary Insurance Claims) Example: The patient has Medicare as their primary insurance and Blue Cross Blue Shield Federal for their secondary insurance. You are not credentialed with Medicare and are credentialed with Blue Cross Blue Shield. You will not be able to get a primary denial from Medicare because you will not be able to file that claim; therefore you will not be able to file the secondary insurance. If you file the secondary insurance without filing the primary, the patient s Explanation of Benefits will return with non-payment awaiting explanation from the primary insurance. Referring Diagnosis or any other diagnosis that the patient may have (It is often helpful to request a Medical History page when patient is being referred from a physician. Some policies may not pay for the referring diagnosis, but may pay for other conditions that the patient may have. Note: Some policies will want a copy of the physician s referral and if the covered diagnosis is not listed on the written referral, the claim will be denied.) Example: A Blue Cross and Blue Shield Federal patient may have been referred with ICD code Morbid Obesity, but the physician may not have noted that the patient is also Diabetic with Gastric Reflux and has Hypercholesterolemia Blue Cross and Blue Shield Federal will pay for the Gastric Reflux and Hypercholesterolemia. A Blue Cross Blue Shield Out-of-State Policy may only pay for Nutrition Therapy for Diabetes , but the patient was referred for Morbid Obesity The insurance will not pay for the claim if you use Morbid Obesity as your ICD code when billing. If you file the claim with a Diabetes code and they ask for documentation including the Physician s referral and it is not documented that the physician referred that patient for Diabetes and that you discussed their diabetes with them in your notes, this claim will be denied. 57

58 Calling the Patient s Insurance for Verifying Patient Coverage & Benefits In a large clinic or practice, verifying a patient s insurance coverage for MNT will increase your billings and decrease a large bill for the patient. For a small practice, calling the patient s insurance company for each and every patient to verify coverage is critical. If a patient is scheduled for an appointment without verifying the coverage, the patient may be liable for a large bill and/or the practice may have to pursue this patient for payment. Verifying coverage for each patient will not constitute a guarantee of payment (which is noted with a recording or representative each time you call), but will improve your chances of reimbursement. With some policies you may be very familiar with the benefits for the patient, but you will still want to ensure that the policy is still an active policy, that there are not any pre-existing clauses on the policy, or that the patient is enrolled in any appropriate programs (ex. Member Health Partnerships) Call the patient s insurance company with all of the patient s information available. Note: o Date and Time of Call o Representative you speak with o Is this policy active? Does the patient have benefits for Procedure Codes (Initial MNT) and (Follow-Up MNT)? Is the patient s diagnosis/condition covered under the plan? - If you are not credentialed with the insurance company, ask o If they pay for out-of-network services? If No, then ask if there is a reference number for the call. If Yes, proceed to the questions below. - If you are credentialed, ask o Is there a referral needed? o Is there a deductible? o Is there a co-pay or co-insurance? o Is there a limit to the number of visits? o Is there a limit to the length of visit (units)? o Are there any exceptions? Note a reference number for the call. Some representatives will suggest you use their name and date/time of the call. If they are in another state, you may ask what time it is in that state. Example: Verification of Insurance 58

59 Patient s First Visit On the patient s first visit, you will need to collect general demographic and health information from the patient, if you are seeing the patient independently. If you are a part of a practice, all of this information should be available in the patient s chart. Demographics Full Name Mailing Address Contact Numbers (Home, Work, Cellular) Alternate Contact ( , Pager) Gender Date of Birth and Age Social Security Number Health Information Weight Loss History Medical History List of Medications If you are in private practice, due to fraud issues, you will need to collect a copy of the patient s insurance card (front and back) and a copy of the patient s driver s license (must be black and white, no color copies) or other photo ID to verify that the patient is indeed the patient presenting the insurance card. If you work in a large practice and think you may need to talk to providers outside your clinic or network, check with your clinic manager whether you need to collect a Medical Record Release. You should know the office policies including insufficient fund fees, noncovered charges by the insurance company, collection fees, or no show fees. If you are in private practice, as part of your intake paperwork, you may also collect a Medical Record Release allowing you to talk to any physicians, specialists, or family members. It will also be important to disclose any financial or office policies including insufficient fund fees, non-covered charges by the insurance company, collection fees, or no show fees. 59

60 Example: Referral Page 60

61 Electronic Claims Submission Services - Verifying Benefits with Blue-e (BCBSNC) With Blue Cross and Blue Shield of North Carolina, you have the option to file your claims using Blue-e versus batch filing or using a filing service. Blue-e is a quick and easy method for filing all of your Blue Cross Blue Shield claims. If you are filing with more than one insurance company, you may choose to use another method of filing. Signing up for this service does not require you to use this service for filing your claim. This service can be very beneficial for verifying benefits. With Blue-e, you will sign up to use this benefit: You can go for a tutorial using: claim.htm Once signed in, go to Eligibility : Enter the member number and/or the member last name, first name, and date of birth. A member number, name, and date of birth are required to search for FEP or out-of-state members. You may enter a single date for the date of service, or if left blank, it will search on today's date. On the Eligibility page, you will see two tabs Member Information and Benefits Member Information TAB to see important information including: o Under Member Information, you find the patient s information including name, address, DOB, and relationship to subscriber. Under policy information, you find the patient s benefit period which is listed under Effective Date. This will be when the patient s policy renews each year. (This will affect the patient s annual deductible or annual number of visits.) Example of Information: Eligibility for 07/01/ /31/9999 Member Information Remember, the benefits you see on this screen are a summary of member benefits and do not indicate payment when a claim is filed. Member Information Member Number: YPPW Name: JANE DOE Date of Birth: 12/8/1967 Address: 300 HAPPY STREET Sex: Female HEALTHY, NC Rel. to Subscriber: SPOUSE Policy Information Product: BLUE OPTIONS Effective Date: 07/01/2009 Group Number: Paid Through/Term Date: 12/31/9999 Group Name: Insurance Type: TOWN OF HEALTHY BLUE OPTIONS-Underwritten Group 61

62 Under member liability summary, you can see what the patient s deductible is and how much the patient has met of their deductible. (This will be helpful for patients who must meet their deductible before services are covered.) Under COB (Coordination of Benefits) summary, this will either be blank or read See Other Insurance Tab Under Additional Information, Pre-existing Condition Waiting Period would be listed or No Pre-existing Condition Waiting Period Example of Information: Member Liability Summary In-Network Single Family Coverage Max per Year-to-Date Max per Benefit Year-to-Date Benefit Period Remaining Period Remaining CoInsurance 40% $ $ $ $ Deductible $ $ $ $ Out-Of-Pocket $ $ $ $ Out-of- Network Single Family Coverage Max per Year-to-Date Max per Benefit Year-to-Date Benefit Period Remaining Period Remaining CoInsurance 60% $ $ $ $ Deductible $ $ $ $ Out-Of-Pocket $ $ $ $ COB Information: No other insurance information on file. Additional Information: Pre-existing Condition Waiting Period 06/07/2006 to 06/07/

63 Benefits TAB Under the Benefits tab, click General Benefit Information, and then Other Medical to see Nutrition Benefits. If there is a copay, coinsurance, or deductible, you will see it listed. This is an example of a Blue Options policy: Nutritional Counseling Diab In Dmp INDIVIDUAL COVERAGE LIMIT - UNIT Benefits Usage: VISITS: 6; 6 remaining for SERVICE YEAR Nutritional Counseling Diab Not In Dmp In Network COINSURANCE: 40% per SERVICE YEAR Nutritional Counseling INDIVIDUAL COVERAGE LIMIT - UNIT Benefits Usage: VISITS: 6; 6 remaining for SERVICE YEAR Nutritional Counseling Out of Network Diab No Dmp COINSURANCE: 60% per SERVICE YEAR Dmp = Diabetes Management Program Verifying Benefits with Webclaims (Medicaid) With Medicaid, you also have the option to file your claims electronically versus batch filing or using a filing service. Again, you may only use this service to verify benefits. To sign up, visit NC Tracks web site at You will complete and Electronic Claims Submission (ECS) Agreement for Individuals or Groups. Once you have signed up for this service, you will go to to sign in and review patient benefits and claims. 63

64 V. Filing Insurance Claims Claims submission will vary based on the type of facility you will be billing from. Example: The Health Insurance Claim Form (CMS-1500) is used by Allied Health professionals, physicians, laboratories and pharmacies to bill supplies and services. However, if you are in an institution, you will bill on a UB-04 form. Example: Hospitals, rehabilitation centers, ambulatory surgery centers, & clinics. If you do not own your own practice, you should check with your billing department. Billing the insurance company You may bill the insurance company for your face-to-face time with the patient. This will be billed in 15 minute increments referred to as units. (**See page 71 Units). You cannot bill for any equipment, goods, or supplies used in carrying out your services. Some offices may use special equipment that may determine body fat, VO2-Maxx, or metabolic rate, which may not be included in standard office services. You may not add these fees, above and beyond the time spent using this equipment, to your charges. If this service is available to the patient above and beyond standard practice, at an additional fee, the provider must provide the patient with notification that these services are not covered and have them sign a release acknowledging that in order to receive these services, they will be the patient s own expense. Telephone consultations are non-covered services and are not reimbursed by BCBSNC and most other insurance companies. You may bill patients directly for these services only if this is your standard practice procedure, and the patient has previously received a written statement of this procedure, or your standard procedure for telephone consultations is posted in your office in a prominent location. Collection of Fees from Patient Except for copayments, a contracted provider shall not collect any amount whatsoever from patients prior to receiving a notification of payment from the insurance company, including, but not limited to Deductible, Coinsurance, or deposit amounts. (**See page 76 Notification of Payment). Waiving of Fees Provider shall not waive any portion of a Patient s Deductible, Coinsurance, Copayment or penalty amount that may be required under a Patient s Health Benefit Plan. Time Limitations for Filing Claims To be eligible for payment, claims must be received by BCBSNC within 180 days of the date of service. All Medicaid claims must be received by Electronic Data Systems (claim filing) within 365 days of the date of service in order to be accepted for processing and payment. 64

65 Billing Rates When you bill an insurance company, you will bill for your usual and customary charges. All agencies will be billed the same fee for ALL recipients who receive the same service from you. Example: You may bill all patients $25.00/unit for services, which would be $100/hour. This would be your usual and customary charge. This would be the rate that you bill the patient or if the patient has insurance, the insurance company. You may be reimbursed by Insurance Company A at a rate of $17.40/unit, which would be $69.60/hour. You may be reimbursed by Insurance Company B at a rate of $16.13/unit, which would be $64.52/hour. You may be reimbursed by Insurance Company C at a rate of $21.23/unit, which would be $84.92/hour. These rates would be your reimbursement based on your set fee schedule agreed upon when you contracted with that insurance company. Sometimes fee schedules are merely the reimbursement rate set forth by the insurance company, some fee schedules are negotiable. Missed Appointments If you are in a facility, you will want to speak with your contracting department to review your reimbursement rates Each insurance company has different policies in regards to these charges. Many medical providers or specialists have started charging a fee to patients that miss their appointments or cancel with less than 24 hours notice. BCBSNC does not cover charges for missed appointments. You may bill members directly for missed appointments only if this is a standard procedure for your practice, and the member has previously received a written statement of this procedure, or your standard procedure for missed appointments is posted in your office in a prominent location. Centers for Medicare and Medicaid Services (CMS) consider missed appointments to be part of the provider's overall cost of doing business and, therefore, prohibits Medicaid providers from billing a Medicaid recipient for a missed appointment. 65

66 Understanding CMS 1500 Forms What is a CMS 1500 form? The Form CMS-1500 is the standard claim form used by a non-institutional provider to bill for services. The Form CMS-1500 answers the needs of many health insurers. It is the basic form prescribed by CMS for the Medicare and Medicaid programs for claims from physicians and suppliers. The Form CMS-1500 has space for physicians and suppliers to provide information on other health insurance. It has received the approval of the American Medical Association (AMA) Council on Medical Services. Based on HIPAA (Health Insurance Portability and Accountability Act) law, some plans may require providers to file claims electronically unless the provider meets certain examptions. Check payer policies. Paper claims are rarely used by practices or private practice RDs due to the overwhelming task of processing paper claims. You should be familiar with paper claims because some insurers may only accept paper claims if you are not credentialed with them or the claim has to be specially reviewed. Since most paper claims submitted to Medicare and other insurance companies are electronically read using Optical Character Recognition (OCR) equipment, it is very important that the information is clear and easily read. Troubleshooting Basics: Use only an original red-ink-on-white-paper Form CMS-1500 claim form which are often available through Office or Medical Supply companies. Use dark ink to write or print on the CMS-1500 form. Do not print, hand-write, or stamp any extraneous data on the form. Do not staple, clip, or tape anything to the Form CMS-1500 claim form. Remove pin-fed edges at side perforations. Use only lift-off correction tape to make corrections. Place all necessary documentation in the envelope with the Form CMS-1500 claim form. Format Hints: Do not use italics or script. Do not use dollar signs, decimals, or punctuation. Use only upper-case (CAPITAL) letters. Use 10- or 12-pitch (pica) characters and standard dot matrix fonts. Do not include titles (e.g., Dr., Mr., Mrs., Rev., M.D.) as part of the beneficiary s name. Enter all information on the same horizontal plane within the designated field. Follow the correct Health Insurance Claim Number (HICN) format. No hyphens or dashes should be used. The alpha prefix or suffix is part of the HICN and should not be omitted. Be especially careful with spouses who have a similar HICN with a different alpha prefix or suffix. Ensure data is in the appropriate field and does not overlap into other fields. Use an individual s name in the provider signature field, not a facility or practice name. 66

67 The format of CMS 1500 is simply a guide of information that you will need for filing a claim. Many of the online claims processing uses the CMS 1500 as a template for all claims. The information below simply identifies the most requested information required to complete the CMS 1500 form or most online claims programs. What information is required for a CMS 1500 form? 1) Show the type of health insurance coverage applicable to this claim by marking the appropriate box. (ex. if a Medicare claim is being filed, check the Medicare box) 1a) Enter the patient's insurance ID Number. (This may be listed as Medicare Claim Number, Medicaid Identification Number, Sponsor s SSN, Subscriber ID, ID, Identification Number, ID #) ) Enter the patient's last name, first name, and middle initial. Smith, John J 3) List patient s birth date. MM = Month (e.g., January= 01) DD = Day (e.g., Jan05 = 05) YY = 2 position Year (e.g., 1998 = 98) Place an X on the correct sex/gender. x X 4) List the insured s Last Name, First Name, and Middle Initial This will be the primary insured s information. If the patient is the primary then the relationship to insured is self (see step 6), then this will be the same information as #2. Many programs will just let you copy the information with shortcut button. Blue-e (**See page 75 Blue- e) will allow you to leave this section blank for all in-state Blue Cross Blue Shield policies (Blue Options, Blue Advantage, Blue Care, Employer Based Blue Policies, HSA or HRA plans, State Health Plan), but will not allow you to leave this blank for Federal or Out of State Plans. Smith, Sally L 67

68 5) List the patient s address. 18 Healthy Place Apt C S Austin NC S S 6) Place an X over the appropriate relationship to insured. If patient is the primary insured, mark self If patient is married to the primary insured, mark spouse If patient is the child of the primary insured, mark child If patient is a dependent of the primary insured in another format (ex. Dependent parent), mark other X 7) Enter the insured's address and telephone number. This should be the address that matches the patient s insurance card mailings. When the address is the same as the patient's, enter the word SAME. Blue-e (**See page 75 Blue- e) will allow you to leave this section blank for all in-state Blue Cross Blue Shield policies (Blue Options, Blue Advantage, Blue Care, Employer Based Blue Policies, HSA or HRA plans, State Health Plan), but will not allow you to leave this blank for Federal or Out of State Plans. 18 Healthy Place Apt C S Austin NC S S 10) There are some cases that you will have to note whether the patient s condition is due to employment, accident, etc. 12) The patient or authorized representative must sign and enter either a 6-digit date (MM DD YY), 8-digit date (MM DD CCYY), or an alpha-numeric date (e.g., January 1, 1998) unless the signature is on file. The patient's signature or the statement signature on file in this item authorizes release of medical information necessary to process the claim. Signature by Mark (X) - When an illiterate or physically handicapped enrollee signs by mark, a witness must enter his/her name and address next to the mark. 01/05/

69 13) The patient s signature or the statement signature on file in this item authorizes payment of medical benefits to the physician or supplier. 17)Enter the name of the referring or ordering physician if the service was ordered or referred by a physician (if it is required by the insurance company). Enter the referring, ordering or supervising provider s first name, middle initial, last name and credentials. In-state Blue Cross and Blue Shield policies do not require a physician s referral, but some policies do. If it is not required, you may leave this blank. Joseph H Smith, MD Referring NPI # Your NPI # 17a) Enter 1G in the small box and the Provider s UPIN in the larger box to the right. UPINs or unique physician identification number, are six-place alpha numeric identifiers assigned to all physicians. 17b) Enter the 10-digit NPI number of referring, ordering or supervising provider. 21) Enter the patient's diagnosis/condition. (**See page 56 or Appendix I Diagnosis Codes) Only one code is required. Enter up to four diagnoses in priority order ) Prior authorization number may need to be listed if required by insurance company. 69

70 24) There are 6 horizontal service lines in section 24. This will allow you to bill for up to 6 different services or dates of service. Most insurances will not allow dietitians to bill for more than one service in a 24 hour period. Some insurances have limits on how often you can bill for your services. 24a) Enter an 8-digit (MMDDCCYY) date for each service. This will be the same date b) Enter the appropriate place of service code. Code 11 Office Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, State or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis d) Enter the procedure code. (**See page 54 CPT or Procedure Codes) Modifiers are not required. Leave blank e) Enter the diagnosis code reference number as shown in item 21 to relate the date of service and the procedures performed to the primary diagnosis. If more than one diagnosis code is indicated, the provider shall reference only one of the diagnoses code. 1 24f) Enter the charge for each listed service. (**See page 65 Billing Rates) List dollars to the left of the dotted line and cents to the right

71 24g) Enter the number of units representing the length of your visit. 3 What is a unit? A unit is the direct (one on one; face to face) time spent in patient contact in 15 minutes increments. This does not include time spent with office staff completing paperwork, doing body assessments, or collecting payments unless that time is spent directly with the provider. For any single CPT code, providers bill for a single 15 minute unit for visits greater than (or equal to) 8 minutes and less than 23 minutes. Time intervals for larger numbers of units are as follows: Example 1 unit > 8 minutes < 23 minutes = 15 minutes 2 unit > 23 minutes < 38 minutes = 30 minutes 3 unit > 38 minutes < 53 minutes = 45 minutes 4 unit > 53 minutes < 68 minutes = 1 hour 5 unit > 68 minutes < 83 minutes = 1 hour 15 minutes 6 unit > 83 minutes < 98 minutes = 1 hour 30 minutes 7 unit > 98 minutes < 113 minutes = 1 hour 45 minutes 8 unit > 113 minutes < 128 minutes = 2 hours The pattern remains the same for treatment times in excess of 2 hours. Example: If a patient had an appointment at 1:00 pm. She arrived at 1:05 pm and started filling out paperwork and was weighed in by the office assistant. You started your consult with her at 1:15 pm and completed it at 1:58 pm. Your visit would be 43 minutes long and you would bill for 3 units. 24j) Enter the rendering provider s NPI number in the lower unshaded portion. Medicaid patients: In the case of a service provided incident to the service of a physician or non-physician practitioner, when the person who ordered the service is not supervising, enter the NPI of the supervisor in the shaded portion. Enter NPI in the small box to the left of this Supervising Physician NPI # Your NPI # 71

72 25) Enter the provider s Federal Tax ID (Employer Identification Number or Social Security Number) and check the appropriate check box. Tax identification information is used in the determination of accurate National Provider Identifier reimbursement. Reimbursement of claims submitted without tax identification information will/may be delayed. This section does not need to be completed for Blue-e. (**See page 75 Blue- e) X or X 27) Check the appropriate block to indicate whether the provider accepts assignment. If you are credentialed with a particular insurance agency, you have contracted a rate with them and you will accept their assigned payment. X 28) Enter total charges for the services (i.e., total of all charges in item 24f). Generally this number will be the same as the charge for one date of service. If you are completing the CMS 1500 form for more than one date of service for the same patient, this will be the total of all dates of service charges ) Enter the signature of provider of service or supplier, or his/her representative, and the 8-digit date (MM DD CCYY) the form was signed. Medicaid patients: In the case of a service that is provided incident to the service of a physician or non-physician practitioner, when the ordering physician or non-physician practitioner is directly supervising the service, the signature of the ordering physician or non-physician practitioner shall be entered in item 31. If a physician, supplier, or authorized person's signature is missing, but the signature is on file; or if any authorization is attached to the claim or if the signature field has "Signature on File" and/or a computer generated signature. This section does not need to be completed for Blue-e. (**See page 75 Blue- e) 33) Enter the provider of service/supplier's billing name, address, ZIP Code, and telephone number. 72

73 Example: CMS 1500 Form 73

74 Electronic Claims Submission Services Submitting Claims with Blue-e (BCBSNC) Go to and sign in Once signed in, go to Billing, CMS1500, Enter the patients ID, and Add a claim Submitting Claims with Webclaims (Medicaid) The process of submitting claims to Medicaid through electronic media is referred to as electronic commerce services. EDS will process claims submitted through file transfer protocol and asynchronous dial-up. By submitting claims electronically, providers have the advantage of expedited claims processing and improved cash flow. Electronic claims software includes time-saving features such as automatic insertion of required claims information, retrieval of previously submitted claims from backup files, and generation of lists of commonly used billing codes. Claims submitted electronically by 5:00 p.m. on the cut-off date are processed in the next check write. Prior to submitting electronic claims, providers must agree to abide by the conditions for electronic submission outlined in the Electronic Claims Submission (ECS) Agreement. The ECS Agreement must be submitted and approved prior to submitting claims electronically, regardless of how claims are submitted through a clearinghouse, with software obtained from an approved vendor, or through the NCECS Web Tool. Go to to sign in Submitting Claims on Paper with Medicaid There are some situations in which a claim must be submitted on paper. Only claims that comply with the exceptions listed on the Division of Medical Assistance s (DMA) web site may be submitted on paper. All other claims are required to be submitted electronically. When completing the paper claim form, use black ink only. Do not submit carbon copies or photocopies, and do not highlight the claim or any portion of the claim. For auditing purposes, all claim information must be visible in an archive copy. EDS uses optical scanning technology to store an electronic image of the claim, and the scanners cannot detect carbon copies, photocopies, or any color of ink other than black. Carbon copies, photocopies, and claims containing a color of ink other than black, including highlighting, will not be processed and will be returned to the provider. For information related to claim filing requirements and billing guidelines, refer to N.C. Medicaid program information and policies, found at N.C. Medicaid programs and policies are addressed separately and maintained by the authorized sections of DMA. 74

75 Example: Blue e CMS Claim Submission 1.Insured s ID Number 2.Last Name of Patient First Name of Patient 3.Patient s Birth Date (enter date without any dashes ( ) for Jan 1, 2001) Sex (F or M) 6.Patient s Relationship to Insured (Self or Spouse or Child) 7.Insured s Address (Only needed if Federal or Out of State) **NOTE: Blue-e has an autofill program for all BCBSNC policies which completes the information for 2, 3, 4, 5, 6, and (1) Diagnosis Code You must list at least 1 code and reference it in 24 E. (enter code without any decimals for ) 24 A. Date of Service (enter date without any dashes ( ) for Jan 1, 2001) start and finish (usually the same day) B. Place of Service (11 for Office) D.CPT see CPT codes E. The number to the left of the Diagnosis Code (example 1) F. Enter Charges (enter without any decimals for $100.00) G. Enter number of units charged (example 4) J. Enter your NPI number (You may enter claims for more than one date of service on the same patient.) 28.Enter your total charges (enter without any decimals for $100.00) Click SUBMIT 75

76 Filing Primary and Secondary Insurance Claims When a patient has a primary and secondary (or more) insurance companies, you will file in the order that the patient reports. You will need to wait until the primary insurance benefits are paid or denied before submitting to the secondary insurance. Once you receive the Explanation of Payment (EOP) (**See below Notification of Payment), you will then document on the claim any write-off or discounts for which the patient is not held responsible, as this will help coordinate the claim correctly on the first submission. Example: If the claim is filed for 4 units at $ and the EOB is returned that the patient s responsibility is $71.40, you will then file the claim with the secondary insurance for $71.40, not $ because that is the agreed upon rate that the primary insurance company contracted with you. You may receive all that you bill for if the secondary insurance company reimburses at a higher rate, or you may receive less. If you file the claim electronically with primary insurance, you will most likely need to send in a copy of the explanation of payment of the primary insurance to the secondary insurance. Do not paste, tape, or staple the explanation of payment to a claim. You may also choose to file the secondary claim electronically, wait for EOP which states that it is awaiting coordination of benefits with the primary. You would then call the secondary insurance company and make a contact and document a reference number of the call along with a fax number you can fax the primary explanation of payment to. Both methods will take time, but electronic claims are much easier to track. Notification of Payment or Explanation of Payment (EOP) or Explanation of Benefits (EOB) North Carolina General Statues have established a legal requirement for prompt payment of medical claims. An insurer shall, within 30 calendar days after receipt of a claim, send by electronic or paper mail (notification) to the claimant (provider): (1) Payment of the claim. (2) Notice of denial of the claim. (3) Notice that the proof of loss is inadequate or incomplete. (Asking for more information from you, the provider, Example Medical Records, Physician s Written Referral, etc.) (4) Notice that the claim is not submitted on the form required by the health benefit plan, by the contract between the insurer and health care provider or health care facility, or by applicable law. (5) Notice that coordination of benefits information is needed in order to pay the claim. (Informing you, the provider, that the patient has another insurance company and that you should either file the claim with the primary insurance or that they are awaiting payment from the primary) (6) Notice that the claim is pending based on nonpayment of fees or premiums. Health benefit plan claim payments that are not made in accordance with this section shall bear interest at the annual percentage rate of eighteen percent (18%) beginning on the date following the day on which the claim should have been paid. Generally Electronic Claims Submitted with BCBSNC pay within 7 days with the exception of Federal and Out of State Claims. 76

77 To check Claim Status with BCBSNC with Blue-e: Sign in to Blue-e Go to Billing and then Claim Status Enter the Member ID and Date of Service If viewing Federal or Out of State Members, it may take some time for a result and you will have to come back and view these items later. HAPPY DIETITIAN The screen explanation will look like this, but if you click on the check number you will see details

78 The table below explains key information on the explanation of payment. YPPW

79 Electronic Funds Transfer (EFT) Electronic Funds Transfer (EFT) is a secure method of claims payment. Many insurances electronically transfer funds directly into the bank account of your choice. Blue Cross Blue Shield North Carolina EFT Enrollment BCBSNC gives you an option to enroll in the EFT program or receive paper checks. The following outlines the process for setup of an EFT payment to the provider. Health care provider must submit: (1) a copy of a voided check or an account verification letter on blank letterhead; and (2) an Electronic Funds Transfer Authorization form to BCBSNC Financial Services via fax or through the mail at: BCBSNC Financial Services Attention: Electronic Funds Transfer PO Box 2291 Durham, NC Fax Number: (Contact Phone Number ) Health care providers must submit a separate Authorization for each provider number to be set up for EFT. A provider number may be associated to only one bank account number. BCBSNC Financial Services verifies the bank name and the bank transit or routing number. After verification, EFT status is loaded to the BCBSNC claims system. The average time to set up a provider is five (5) days from receipt of all documentation by BCBSNC. All EFT payments are made to the group provider number level. Medicaid EFT Enrollment Medicaid s only option for payment is EFT. To ensure timely and accurate enrollment in the EFT program, please fill out the form on the following page, attach a voided check (not a deposit slip, starter check, or counter check) and return them by mail, fax, or . You must include your NC Medicaid Billing Provider Number on the form. to: Fax to: Mail to: [email protected] HP Enterprise Services Attn: Finance Dept. EFT Finance Department 2610 Wycliff Rd Suite 401 Raleigh, NC

80 The main challenge of EFTs is identifying the payments that go to your banking account. They do not come in with a detailed explanation of where the deposit came from or whose account this payment should be applied. You must use your EOPs to compare the amount of the deposit. Generally most EFT from BCBSNC are deposited 2 business days later. This is an example of the deposits in a Banking Account Handling Patient Denials and Errors Patient denials decrease with practice. You learn over time, which policies require which information. There are common entry error mistakes such as patient gender or using today s date as the date of birth. There are also errors on the end of the insurance company. Example: A claim with Blue Cross Blue Shield Federal for a patient s office visit was not paid correctly. The visit was 8 units (2 hours) and was denied because it exceeded the benefit coverage. When called, the representative shared the patient only had 4 visits / year and this visit exceeded the benefit. The misunderstanding was the difference between units and visits. There is not a limit on the number of units, only the number of visits. This patient s claim was sent for review, paid the claim, and had 3 remaining visits. Once you receive a claim denial, your first step is to call the insurance company and speak with the claims department. You will then review the claim with the representative to assure that you entered the correct information. Verify that you entered the correct ID #, Name, Date of Birth, Gender, Procedure Code, and Diagnosis Code. Often, this can be resolved easily by resubmitting the claim. Some insurance companies will require you to refile the claim with the words CORRECTED across the top. BCBSNC has an option for you to resubmit the claim electronically through Blue-e simply by resubmitting all the information from the original claim with corrections and choosing Corrected Claim. 80

81 If there are no errors and the patient s policy does cover nutrition therapy, have the representative send the claim for review. In some cases the insurance company will ask for additional notes or a copy of a physician referral. With Medicaid Eligibility Denials If claims are denied for eligibility reasons, the following steps should help resolve the denial and obtain reimbursement for covered dates of service for eligible recipients. Step 1 Check for Errors on the Claim Compare the recipient s eligibility information to the information entered on the claim. If the information on the claim and the recipient s eligibility information do not match, correct the claim and resubmit on paper or electronically as a new day claim. If the claim is over the 365-day claim filing time limit, request a time limit override by submitting the claim and a completed Medicaid Resolution Inquiry form ( Include a copy of the Remittance and Status Report (RA) or other documentation of timely filing. Step 2 Check for Data Entry Errors Compare the RA to the information entered on the claim. If the RA indicates that the recipient s name, MID number, or date of service has been keyed incorrectly, correct the claim and resubmit on paper or electronically as a new day claim. Step 3 When All Information Matches Verify that the recipient s eligibility information has been updated in the state eligibility file by utilizing the NCECS/Recipient Eligibility Verification Web Tool or by calling the AVR system. If the CECS/Recipient Eligibility Verification Web Tool or the AVR system indicates that the recipient is ineligible, submit a Medicaid Resolution Inquiry form to DMA Claims Analysis. Include the recipient eligibility information, the claim, and the RA. Mail to Division of Medical Assistance Claims Analysis 2501 Mail Service Center Raleigh NC The Claims Analysis unit will review and update the information in EIS and resubmit the claim. 81

82 VI. Reference Contact List Blue Cross and Blue Shield (bcbsnc.com) North Carolina Provider Line bcbsnc.com/content/providers/blue-book.htm North Carolina Member Health Partnership Program bcbsnc.com/assets/members/public/pdf/ncbar/mhp_brochure.pdf (brochure) bcbsnc.com/memberhealthpartnerships (enroll) Duke-WellPath (Duke Select & Duke Basic) Blue Cross Blue Shield of NC (Duke Options & Blue Care) State Health Plan PPO shpnc.org State Indemnity Plan & NC Health Choice shpnc.org ncdhhs.gov/dma/healthchoice/index.htm Physician Certification - Federal fepblue.org Eligibility (verify Out of State Coverage) ext 4 Provider Line located on each patient card Inter-Plan Department (BCBSNC liaison for Pmt Out-of-State Claims) Network Management bcbsnc.com/content/providers/application/contacts.htm Charlotte Greensboro Greenville Hickory Raleigh Wilmington Blue-e... bcbsnc.com/content/providers/edi/index.htm Region I Region II Region III Region IV

83 Medicaid Enrolling as a Medicaid Provider (including CCNC/CA) (EVC Call Center): (HP Enterprise Services [EDS] Provider Services) Automatic Deposits (Electronic Funds Transfer) or Billing Issues/Claim Inquiries Claim Submission System, WebClaims Automated Voice Response System (HP Enterprise Services [EDS]): Eligibility & Claim Status Provider Contact List Topics of Interest for Providers 83

84 VII. Appendix I Diagnosis Codes 84

85 Cred ential Dietitian Cover MNT Referral Required Special Required Deductible Copay/ Coinsurance Visit Limit Out of Network Benefits Notes Policy Notes BCBS BLUE CARE, OPTIONS, ADVANTAGE Y Y N MHP or DM dx $0 $0 6 Deductible & coinsurance apply 30%* after initial 6 if DM unlimited* *indicates, require DM dx Check each policy individually. Employer based policies may have carved out certain benefits. BCBS HSA or HRA Y Y N MHP or DM dx AND must meet deductible Varies by policy Deductible & coinsurance apply 6 Deductible & coinsurance apply Deductible & coinsurance apply if DM unlimited* *indicates, require DM dx Check each policy individually. Employer based policies may have carved out certain benefits. BCBS STATE HEALTH PLAN Y Y N None $0 for 4 visits for non- DM, $0 in network for first 6 visits w/ DM $600/800 (std/basic) after 6 th visit applies $25 for all other Dx 4 $0* if DM Dx, 20-30%* after initial 6 (see card) Basic $1600 deduct /50% coins & Standard $1200 deduct /40% coins 6 *indicates, require DM dx BCBS INDEMNITY PLAN NA NA NA NA NA NA NA NA NA These policies are comprehensive major medical policies and do not cover Medical Nutrition Therapy. BCBS FEDERAL Y Y N None Std (104/105) $300 15% 6 75%** Basic (111/112) $0 $ %** **Pt will be responsible for difference in billed amt and allowed amt BCBS OUT OF STATE Y*** varies varies varies varies varies varies varies varies ***If you are credentialed with the local BCBS, you can file these claims. VII. Appendix II Quick Guide to Insurers 85

86 Cred ential Dietitian Cover MNT Referral Required Special Required Deductible Copay/ Coinsurance Visit Limit Out of Network Benefits Notes Policy Notes NC HEALTH CHOICE N Y N See Notes* $0 $0 $300 / plan year N Require DM Dx $5 if stated on front of card Must be Medically Supervised Facility that meets the standards of the National Diabetes Advisory Board MEDICAID N Y Dietitian must see patient incident to physician**** $0 $0 $3 if an adult that does not meet the criteria listed under Notes INITIAL ASSESSMENT 4 units / 270 days RE-ASSESSMENT 20 units / 365 days***** N ****Pt must be 20 yo & under for any dx OR Pregnant/Postpartum & be seen for specific dx codes *****Maximum of 4 units per date of service 86

87 VII. Appendix III Additional Resources General Resource Nutrition Entrepreneurs Nutrition Coverage Fee Schedule Compensation & Benefits Survey of the Dietetics Profession Tips for contract negotiations and establishing MNT rates. Myers EF, Michael P, Duester KC. HealthCare Financing Team J Am Diet Assoc 2001 Jun;101(6): HIPAA 87

88 Index Page CAQH See Council for Affordable Quality Healthcare CMS 1500 example...73 formatting...66 hints...66 information required troubleshooting...66 Contact list, telephone numbers...82 Council for Affordable Quality Healthcare CAQH adding CAQH to existing insurer policy...20 application requirements, example...18 attestation statement benefits of CAQH...17 contracting...23 credentialing data review...20 example...18 FAX cover sheet...22 initial application...20 provider relations...23 BCBSNC example...23 Medicaid example...7-8, 24, 27, 72 Coverage See Insurance CPT codes See Procedure codes Credentialing attestation statement...16 demographic and personal data...14 education and practice history...15 example: BCBSNC...12 how...11 letters of recommendation...13 professional information...16 re-credentialing...16 uniform application...13 uniform application, tips...13 when...10 which...11 why...10 with insurance companies...10 Diagnosis Codes

89 common ICD-9 codes...56 ICD list...84 EIN See Employer Identification Number Employer Identification Number (EIN)...25 application...26 forms...26 sole proprietor See self-employed...25 Fees fee schedule...23 missed appointment...64 procedure...64 waive...64 ICD-9 codes See Diagnosis codes Insurance Claims BCBSNC...61 Blue-e...61 electronic submission...61, 74 enrollment, Medicaid...79 examples , 75, 80 ineligibility...81 benefits tab...61, 63 member information tab...61 submitting claims...74 billing insurance company...64 billing rates...65 co-payments...64 denials, patient...80 electronic funds transfer (EFT) equipment fees...64 errors...80 explanation of payment...78 filing...64, 76 Medicaid...63 out of state...77 payment...79 primary...76 procedures...64 secondary...76 time limits...64 waving fees...64 Insurance...4-6, 10-13, 16-17, 20-23, 27-29, 58-59, 61, 64 patient benefits...29 coinsurance

90 copayment (copay)...29 exceptions...29 out-of-network...29 units limits...29 visits limits...29 assistance with benefits, BCBSNC...31 benefits verification, BCBSNC...31 cards, examples...30, 32, 35-38, 40-41, 44, 46, 48, incident to services...71 Insurance, professional liability...27 patient benefits...29 quick guide to insurers referral documentation...28 special requirements...25 Insurance Coverage...4-6, 10-13, 16-17, 20-23, 27-29, 58-59, 61, 64 verification data needed...59 examples...57 referrals...28, 57 patient example...60 Insurers BCBSNC plans...30 Blue Advantage...30 Blue Care...30 Blue Cross and Blue Shield of North Carolina 4, 11, 23, 30-45, 61, 67-69, 79, 82 Blue Options...30 Classic Blue...37 Duke BCBSNC PPO...34 employer based plans...32 federal basic policy...41 federal standard policy...40 Health Choice health savings account (HAS)...35 Medicaid out of state...44 State Health Plan...38 Medicaid...6-9, 27, 48-53, 69, pregnant or post-partum...51 billing...53 children eligibility...49 coinsurance, co-pay...51 deductible...51 diagnosis codes...51 limit units

91 mandatory services...52 optional services...52 out of network...53 post-partum eligibility...50 pregnant eligibility...50 provider eligibility...48 visits, limits...52 National Provider Identifier (NPI)...4-5, 10-11, 13, 28-29, 54, 66, 76, 85 deactivate NPI...9 definition...6 fee...6 information required...8 obtaining NPI...8 tips...7 where to apply...7 Patient benefits See Insurance Procedure codes...54 Self-employed...25 business losses...25 employees...25 liability...26 social security number (SSN)...25, 27 taxes Universal benefits See Council for Affordable Quality Healthcare 91