Outpatient Reimbursement

The number of allowed hours and disease states that are covered by commercial insurers varies based on the client’s individual insurance plan. You must enroll as a provider with the client’s insurance provider. Some companies may use the standard Medicare fee schedules to determine payment, however these may vary and are often negotiable.

Medicare covers MNT if the beneficiary has Medicare Part B, and one of the following disease states:  diabetes, non-dialysis chronic kidney disease, and post kidney transplant (within 36 months of surgery). Medicare has other specific coverage requirements and limitations, including:

• RDN must have a National Provider Identifier (NPI) and be registered as a Medicare provider

• Physician or other primary care provider referral required annually

• Covered hours limited to three for the first calendar year, two hours for subsequent years

• Service must be provided in person or via telehealth. Due to the COVID-19 pandemic, in March of 2020, the Center for Medicare and Medicaid Services made temporary emergency provisions to broaden the coverage of telehealth services. 

• Reimbursement rates are set and non-negotiable

Medicare may cover additional hours if the client has a significant change in condition that warrants intervention from an RDN, and another physician referral is received.  Other avenues for Medicare payment include intensive behavioral therapy for obesity and cardiovascular disease, and annual wellness visits provided as“incident to” services.

The Academy is promoting legislation that will substantially expand Medicare coverage of MNT. 

Medicaid coverage of MNT varies from state to state. Arizona’s Medicaid program is called the Arizona Health Care Cost Containment System (AHCCCS).  AHCCCS covers nutritional services provided by RDNs when a referral is received from the beneficiary’s primary provider.  AHCCCS will also cover commercial oral nutrition supplements if deemed medically necessary.

As with other insurers, you must register as a provider.  To manage this process, Arizona uses the Arizona Association of Health Plans (AzAHP), a coalition of health plans that serve AHCCCS beneficiaries. Once you are registered as a provider through AzAHP, you do not need to become a provider for each individual insurance company that serves AHCCCS patients.

Steps to become an AHCCCS provider:

• Complete the AzAHP Provider Enrollment Application Form.  This form only needs to be completed once as it can be used by all health plans in the AzAHP alliance.

• Create a provider profile at the Council on Affordable Quality Healthcare (CAQH) ProView Database.  CAQH is a free non-profit credentialing database.  Health plans use this service to obtain your credentialing information, such as licensure and registration. You must grant each health plan access to your information.

• Initiate contract negotiations, which can be finalized after credentialing is completed.

• Receive notification of the Credentialing Committee’s decision, which must be issued within 90 days of application.  If approved, an effective date will be provided.