Insurance

At this time, Jay is currently in network with Aetna, Anthem Blue Cross Blue Shield, Cigna, Connecticare (Emblem Health), Harvard Pilgrim, United Healthcare and Medicare. Please note that Medicare, including the *Advantage Plans, will “only” cover counseling for Type II Diabetes & Renal Disease. Medicare does not cover nutrition counseling for Pre-Diabetes at this time.

 *Please click the + sign below on how Aetna Advantage plans work in practice.

“Traditional” Medicare Plans will “only” cover Type II Diabetes & Renal Disease. Advantage Plans offered by Commercial Carriers adhere to “Traditional” Medicare Guidelines in regards to their coverage for Medical Nutrition Therapy.

Aetna Advantage Plans advertise in their written and online literature that they will provide expanded services for medically necessary conditions such as Pre-Diabetes, Hypertension, Elevated Cholesterol, or anything that would put one at risk for cardiovascular diseases. The average customer service representative will verify this both to their providers and subscribers when calling to verify benefits.

However, in practice “all claims” that are not billed for Type II Diabetes or Renal Disease will be denied. Jay has observed instances where his clients have gotten “non-traditional” claims covered. However, it is a lengthy and often times frustrating process that will require a good deal of organization and persistence. For example, you must document the times of your call, the names and identification of the given agent, and any other details necessary to hold everyone on the call accountable. Even then there are no guarantees of coverage.

Aetna does not allow any form of preapproval in practice for their nutrition providers. Instead, we must submit claims, allow for them to be accepted or denied, and from there engage in a complicated appeals process that requires a time commitment beyond what our office can provide. Please note that even after a successful appeal, your plan still might deny future sessions, despite assurances otherwise, requiring the subscriber to call their insurance carrier’s customer service to get a resolution.

Medicare has guidelines that restrict the ability of its providers to bill their subscribers for “non-traditional” coverage. Therefore, you will be required to sign documentation acknowledging that you are requesting that Jay bills Aetna Advantage for a service not typically covered by your plan and are willing to pay should the claims be denied.

Currently most insurance plans in the State of Connecticut are fully covering telehealth services. Therefore, when you schedule your visit, you will be directed towards the next steps when it comes to setting up a telehealth session. However, it is possible that your insurance plan may impose a cost-share for you to use this service. Therefore, please call your insurance company ahead of time to confirm telehealth coverage prior to scheduling your session.

Currently, Jay is in-network with most commercial insurance plans.

However, this does not mean that all insurance plans will cover consultations. Therefore, you must call your insurance company ahead of time to confirm that your sessions will be covered by your plan. Please follow the instructions for “What questions should I ask when calling my insurance company” for more details.

(Please reach out to the office if you have any additional questions or challenges working with customer service.) 

Please note, that it is the client’s responsibility to call their insurance company ahead of time to confirm coverage. Although this may come across as being a bit reductant at this point, and perhaps a little annoying, Jay does not want any of his clients to ever come across “surprise bills.”

If your insurance plan asks for CPT codes, please provide them with the following codes 97802 & 97803. If they say that they do not cover these codes NEXT ask them for the following CPT codes 99401, 99402, 99403, and 99404. Some plans will also allow us to bill for S9470.

If the customer service representative asks for a diagnosis code (aka ICD 10 codes), please tell them the visit is coded with ICD code: Z71.3

If the Z71.3 is not accepted then provide them with Z72.4 and see if that diagnosis will be covered instead by your plan.

If you are overweight, obese, have pre-diabetes, diabetes, hypertension, or high cholesterol you may want to see what your coverage is for these diagnoses as well.

Your visit will always be coded using “Preventative Coding” (if applicable) to maximize the number of sessions you will receive by your insurance plan. However, if you ONLY have a medical diagnosis (for example, IBS, and are not overweight or have a cardiovascular risk factor) your insurance plan may impose a cost share for your sessions in the form of a deductible, co-pay, or co-insurance.

Your insurance plan will let you know how many sessions you have per calendar year. Depending upon the plan you may have anywhere from zero to unlimited depending upon medical necessity.

A cost share is the amount that you will need to pay as required by your insurance plan towards your services. A cost share can be in the form of a deductible, copay, or coinsurance.

Your sessions will be billed under your plans preventative benefits if it is allowed. Assuming there are preventative benefits there are often NO cost shares associate for your sessions.

Once again, this is something that you want to verify ahead of time.

In the event you have a cost share your plan will be billed directly. Once an EOB (Explanation of Benefits) is received, indicating your responsibilities as a client, you will receive a bill for the amount owed.

For most insurance companies, Dietitian/Nutritionists, are considered specialists. Therefore, your specialist copay is applicable and is payable at the time of the session. This information is often apparent on the front side of your insurance card. However, because your sessions are often billed as a preventative service, the copay is often not applicable.

Generally speaking, you will not receive a bill for a cost share until the claim has been processed.

Do I have coverage for nutrition sessions?

Do I need a referral to see a Dietitian/ Nutritionist?

Are my medical diagnoses covered on my particular plan?

How many visits per calendar year will I receive?

Is there a cost share for these services?

Will I have to pay an additional cost for telehealth services?

Yes. There is currently a glitch in Anthem's system that is preventing Jay from showing in the directory. His team is working with Anthem to have them address the issue but know that it does not affect Jay's In-Network status.