Insurance Benefits and Coverage Information: Checklist for Insurance Benefits and Coverage Verification: Reposted from the Academy of Nutrition and Dietetics

Obtaining and documenting the following information when confirming benefits and coverage details
by phone or online will help ensure accurate understanding of client benefits and inform the potential
payment for the RDN. Documentation of the information in this checklist is essential to resolving
issues related to claims payment should they arise.

Disclaimer: This checklist is designed for information only and does not guarantee payment from an
insurance company or other payer.
• Policy Type: This refers to the patient’s type of health insurance policy. There can be many different types of policies. Medicare Part B, Medicare Advantage (Medicare Part C), Medicaid or CHIP, commercial, or other government-sponsored insurance. Policies can be further described by type: PPO, HMO, EPO or others.

• Benefit period: Confirm that the client’s insurance policy is active. Note the benefit period, the length of time during which a benefit is paid, and the future termination date. Often this benefit period is the same as the calendar year (January 1 – December 31), but in some cases the benefit period differs. It is important to pay attention to the benefit period, especially regarding the number of visits/benefit period and if/when clients have deductibles.

• Does the policy have nutrition counseling/MNT benefits: Document whether the client has a benefit for MNT/nutrition counseling. Specify or look up (online verification) the MNT CPT® codes during the benefits verification. In most instances you will also need to provide patient diagnosis(es) information using relevant ICD10-code(s) established by a physician or other provider qualified to assign medical diagnoses. ICD-10 The International Classification of Disease, Clinical Modification (ICD-CM) is a classification used in assigning codes to diagnoses associated with inpatient, outpatient, and physician office utilization in the U.S. For more information, visit the Academy’s website. Note which of the client’s diagnoses/conditions relevant for the MNT, via specific ICD-10 codes, are covered or not covered under the individual’s policy. The assignment of medical diagnoses is a regulated activity. It is not within the scope of practice of the RDN to assign any diagnoses (by assigning ICD-10) in any state.

• Confirm any exclusions for coverage for MNT: Document the situations under which MNT is not covered under the individual’s policy.

• Confirm MNT benefits based on provider status (in-network vs. out-of-network):
In-network benefits apply to services provided by a dietitian contracted with the health plan or organization. Out-of-network benefits may be provided by a dietitian that is not credentialed with the patient’s health plan. Out-of-network benefits are often accessible at a higher financial responsibility to the insured patient.

• Is a referral required from a physician or other qualified healthcare provider? In some instances, a referral for MNT from a client/patient’s healthcare provider may be required. Be sure to confirm what provider type can make the referral under the patient’s plan.
• Is prior authorization required? If yes, inquire about this process.

• Reference (phone or other form of online confirmation) number: Obtain the reference number for the benefits confirmation. This is a very important step and may be essential in resolving any issues regarding coverage for the patient and payment for the RDN

In/Out-of-Network Boxes
• In/out-of-network benefits as applicable: If you are not in network with a client’s plan, confirm the details of the out-of-network benefit, if applicable.
• Request and document any limits on the number of visits/sessions, or hours: Limit on the number of units might be stated in the health plan billing policies but is not something that is part of an individual’s plan policy details.
• Confirm whether any deductible applies: The specified dollar amount for certain covered services that the member must incur before the insurance pays any claims. Clients may have different deductible requirements for in-network and out of network 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.
• Copayment (copay): A fixed dollar amount which is due and payable by the member at the time a covered service is provided. (Example: $25)
• Coinsurance: The sharing of allowable charges by the insurance company and the patient for
covered services, usually stated as a percentage of the allowed amount after the deductible has
been satisfied. (Example: Insurer pays 80%; Member’s 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.
• Reference number: Document the electronic or telephonic reference number for the benefits verification.
• Date/time/representative: Document the date and time of the call as well as the representative’s name

(© April 2020 Academy of Nutrition and Dietetics)

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