Independent Study by
Barrie Lynne Sutton
Dietetic Intern 2015

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Educate NHDA Members on Insurance Reimbursement, Obtaining an NPI and Credentialing with Insurance Companies
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Research Credentialing Processes for Cigna, Anthem, Harvard
Pilgrim, Aetna, Medicaid, NH Healthy Families, and Well Sense
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List Coverage Available Through Medicaid Managed Companies
NH Healthy Families and Well Sense
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Explain Medicare Nutrition Benefits
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Explain Medicaid Nutrition and Diabetes Self-Management
Coverage
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Request Permission from North Carolina Dietetic Association to
Adapt their Billing Guide for New Hampshire
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Meet with Private Practice Dietitians

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Participate in Advocacy and Introduction of HR 1686 Preventing
Diabetes in Medicare Act
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Submit Grant Proposal for Pre-Diabetes Education Funding

Target Population for the Reimbursement
Guide: NHDA Members

1) Request permissions from the authors of the North
Carolina Billing Guide
2)
3)
4)
5)
6)
Research process of obtaining NPI
Research process of credentialing with insurance companies
Research CAQH (Council for Affordable Quality
Healthcare)
Research common insurance companies’ credentialing processes in New Hampshire (Cigna, Anthem, Harvard
Pilgrim, Medicaid, Aetna)
Research EIN, professional liability insurance, etc..

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10-digit intelligence free identifier number used for financial and administrative purposes

Every provider has a unique identifier number
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Introduced following HIPPA regulations to keep information, such as provider specialty and location, off of financial and administrative paperwork

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Every insurance company may have a unique credentialing process
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Begin credentialing process 6 months before beginning to see clients, as it can be time consuming
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Identify which insurance companies are most popular in your area
◦ In NH: Anthem, Aetna, Harvard Pilgrim, Cigna,
Medicaid

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Visit the website for each individual insurance company for credentialing instructions

Many insurance companies now credential through a “common credentialing application” known as the Council for
Affordable Quality Healthcare (CAQH)

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Online service intended to eliminate need for credentialing individually with every insurance company

Benefits
◦ Time Saving
◦ Minimizes Paperwork
◦ Keeps Information Current
◦ Free Service

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A nine-digit number assigned by the IRS

Required for certain individuals who do not have employees and employers to file various business tax returns

If you and/or your business does not require an EIN, you will file using your
SSN


Found on the IRS website in the Small
Business and Self-Employed Sections

Apply by:
◦ Online Application (preferred)
◦ Fax
◦ Telephone
◦ Mail

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You might consider this if you do not have interest in hiring employees or obtaining an EIN

In this case, a SSN may be used in place of an EIN only if your business…
◦ Has no employees and is not required to file excise, employment, alcohol, tobacco, or firearms tax returns

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Advantages…
◦ Ability to deduct your business losses to the extent of your total income from all sources
 Interest, dividends, and gains from sales of nonbusiness property
◦ Avoid paying doubles taxes
 Personal income taxes + business taxes on same dollar income

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Reasons to explore using other business entities…
◦ As a sole proprietor, you are personally liable for all of the debts of your sole proprietorship
◦ Higher income taxes because you must report your business income on your personal tax return


Medicare
◦ Medicare Part B covers MNT for certain cases
 Diabetes (type 1 or type 2 ONLY)
 Kidney Disease
 Kidney Transplant in last 36 months
 Doctor Referral Required

Medicaid
◦ Does not cover dietary services for weight loss, nutritional counseling, and exercise programs

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NH Healthy Families
◦ Same coverage as Medicaid plus additional approved services
◦ MNT covered with no listed Prior Authorization or limitations noted

Well Sense
◦ Covers what Medicaid requires plus additional authorized services
◦ MNT covered with Prior Authorization that deems it as necessary
◦ Reimbursement up to $200 for gym memberships and Weight Watchers programs
◦ Dietary services for commercial weight loss and exercise programs not covered


Currently Medicare only covers MNT for
Type 1 and Type 2 Diabetes
NOT Pre-Diabetes

Bill proposed to extend MNT coverage for individuals diagnosed with Pre-Diabetes


29.1 million (1 out of 10) Americans have diabetes

86 million Americans estimated to have pre-diabetes

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7 out of 10 people who are aged 65 or older, and eligible for Medicare are affected by diabetes or pre-diabetes
◦ For 5 out of 10 of these people, diabetes may be prevented with access to lifestyle intervention, such as MNT provided by a registered dietitian


In 2007 about 5% of NH residents had diabetes, of these half were covered by
Medicare

Most recent statistics show 7% of NH residents now have diabetes

By 2050 the CDC estimates as many as 1 in 3 people will have diabetes


Medical expenses for those with diabetes is 2.3 times higher than for those without.
Why?
◦ Medications
◦ Complications
 Vision loss
 Renal disease
 Heart disease
 Limb amputations
 Death


In 2009 the total cost of diabetes and its complications exceeded $876 million
◦ Two-thirds of this cost is the direct result of medical bills
◦ One-third of this cost is from indirect costs
 Lost work productivity
 Disability
 Pre-mature death


Advocate and Support the Bill HR 1686:
Preventing Diabetes Through Medicare Act
◦ Access for individuals to MNT with an RD when diagnosed with pre-diabetes
◦ Reduce the risk of developing Type 2 Diabetes
◦ Reduce overall tax money being used to treat diabetes and put money towards preventative measures, which cost less in the long run


Allen Foundation
◦ Funds non-profit organizations and nutrition educations programs
◦ Proposed program would be 12 one-hour class sessions held once a month for individuals at risk for developing type 2 diabetes or who have pre-diabetes
◦ Classes would be taught by a Dietitian with aid from Dietetic Interns


Classes would cover making healthy food choices, portion sizes, and focusing on making lifestyle changes to reduce the risk of type 2 diabetes

Classes would be designed to incorporate goal-setting to encourage participants and provide accountability


Continue researching and writing
Reimbursement Guide elements
◦ Contacting insurance companies as needed

Follow up need and feasibility to create nutrition education modules for prediabetes

Follow up the progress of Bill HR 1686

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National Plan and Provider Enumeration System. “How to Apply for an NPI”. Accessed 20 Apr 2015. https://nppes.cms.hhs.gov/NPPES/Welcome.do
Justia US Law. “2014New Hampshire Revised Statutes Chapter 420-J: Managed Care Law.
Accessed 20 Apr 2015. http://law.justia.com/codes/new-hampshire/2013/title-xxxvii/chapter-420j/section-420-j-4
Anthem Blue Cross Blue Shield. “Join Our Network”. Accessed 21 Apr 2015. https://www.anthem.com/wps/portal/ahpprovider?content_path=provider/nh/f6/s0/t0/pw_e22931
7.htm&rootLevel=5&state=nh&label=Join%20Our%20Networks
Cigna. “Credentialing and Recredentialing”. Accessed 22 Apr 2015. http://www.cigna.com/healthcare-professionals/resources-for-health-care-professionals/doingbusiness-with-cigna/credentialing-and-recredentialing?WT.z_nav=healthcareprofessionals%2Fresources-for-health-care-professionals%2Fdoing-business-with-cigna%2Fhealthprovider-practice-management-tools%3BBody%3Bcredentialing%20process
Harvard Pilgrim. “Join Harvard Pilgrim’s Provider Network”. Accessed 22 Apr 2015. https://www.harvardpilgrim.org/portal/page?_pageid=253,1117993&_dad=portal&_schema=POR
TAL
Aetna. “Medical Application Request Form.” Accessed 23 Apr 2015. https://www.aetna.com/healthcare-professionals/forms/medical-application.html
Medicare. “Details for CMS 855I”. Accessed 24 Apr 2015. http://www.cms.gov/Medicare/CMS-
Forms/CMS-Forms/CMS-Forms-
Items/CMS019477.html?DLPage=1&DLEntries=10&DLFilter=855&DLSort=0&DLSortDir=ascending

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New Hampshire Healthy Families. “Become a Provider”. Accessed 24 Apr 2015. http://www.nhhealthyfamilies.com/for-providers/become-a-provider/
Well Sense. “Credentialing and Provider Enrollment Process.” Accessed 25 Apr 2015. http://www.wellsense.org/providers/join-our-network
Council for Affordable Quality Healthcare. “About CAQH”. Accessed 25 Apr 2015. http://www.caqh.org/about/about-caqh
Internal Revenue Services. “Apply for an Employer Identification Number (EIN)”. Accessed 7 Jul
2015. http://www.irs.gov/Businesses/Small-Businesses-&-Self-Employed/Apply-for-an-Employer-
Identification-Number-(EIN)-Online