Identifying Benefit Policies and Coverage Guidelines

Close-up of Health Insurance Claim Application Form with pen and stethoscope

9 Steps to Identify DSMES Benefit Policies and Coverage Guidelines

  1. Identify the healthcare insurers you will bill such as Medicare Part B, State Medicaid, or private healthcare plans. To learn about health insurance carriers in your area, click this link. Then click on your state to find a listing of insurers in your area.
  2. Know that each insurer has multiple health plans. Plan benefits and reimbursement rules can vary.
  3. Identify if medical nutrition therapy (MNT), DSMES, and related benefits are covered by these plans.
  4. For each covered benefit, in each plan, identify procedure codes, frequency (hours, visits), and time frames (calendar or rolling year) for initial and follow-up interventions.
  5. For each covered benefit, in each plan, identify payable International Classification of Diseases (ICD)-10 diagnosis codes.
  6. For each covered benefit, in each plan, identify approved billing providers and rendering providers.
  7. For each covered benefit, in each plan, identify reimbursement rates.
  8. For each covered benefit, in each plan, identify the approved places of service and the participant’s eligibility based on clinical data (e.g., BMI >30, FPG >126 mg on 2 tests, etc.).
  9. Know coding, billing, and reimbursement rules of thumb:
    • Never “guess” as to which procedure codes to use on claims. Do your homework with each insurer.
      • Never select a procedure code JUST because of a good reimbursement rate. Always remember that the code must match code terminology and the nature of the service furnished. The benefit’s coverage rules must be met.
    • NEVER bill a procedure code that limits billing providers to physicians, nurse practitioners (NP), physician assistants (PA), clinical nurse specialists (CNS) when the service is rendered by non-physician staff or physician extenders such as registered nurses (RN), registered dietitians (RD), certified health education specialists (CHES), medical assistants (MA), etc., unless the insurer specifically allows this.
    • Regarding the billing method “incident to physician services,” ALWAYS check FIRST with each insurer to determine IF this billing method is allowed, mandated, or even statutorily prohibited for the benefit being billed.
      • If so, always identify the insurer’s requirements for office physicians and ancillary staff for this type of billing.
      • This billing method is statutorily prohibited for Medicare DSMT and MNT benefits.
    • Track your reimbursement retrospectively (on a quarterly basis). For claim denials and rejections:
      • Identify the reason why.
      • Fix the problem. (Approximately 80% of the time, it is an error by the entity’s billers.)
      • Re-bill as soon as possible. (There is usually a limit of 12 months.)

List adapted and used with permission of Mary Ann Hodorowicz Consulting, LLC.