I start with a thorough assessment of your current lifestyle, preferences, and goals. Based on this, we craft a personalized wellness plan suited to your individual needs.

My approach is holistic and personalized. I focus on sustainable change, empowering you with the knowledge and tools to maintain your wellness journey long-term.

Medicare covers 3 hours of medical nutrition therapy the first year and 2 hours every year after for the following conditions (with a doctor’s referral):

• Diabetes

• Chronic Kidney Disease Stages 3-5 (pre-dialysis)

• Kidney transplant within the last 36 months

If there is a change in status, Medicare will cover unlimited sessions with another doctor’s referral. I will work with your provider to obtain referrals.

Medicare Advantage (Medicare Part C) generally covers the same conditions as Medicare Part B. For specific information, please contact the insurance company that provides your Medicare Advantage plan.

Checking In-Network Benefits

Call the phone number for customer service, which is usually located on the back of your insurance card - ask to speak to the benefits department. If your employer provides your plan, your HR department may be able to call on your behalf.

Question 1: Is this dietitian in-network with my insurance plan? They should ask you what the tax ID and NPI numbers are.

• Tax ID#: 99-2530468
• Provider's Name: Summer Spires
• NPI: 1588282321

Question 2: Ask if telehealth is covered and if out-of-state is covered. If telehealth is covered, ask:

• Which place of service can be used: 11, 10, or 02

• Which modifiers are needed: GT, 33, or 95

Question 3: Does my plan cover nutrition counseling?

• Do I need a referral or prior authorization from my PCP?

• How many visits are covered per year?

Question 4: Can you check these CPT and diagnosis codes?

• CPT: 97802, 97803, 99404, S9470

• ICD-10: Z71.3*

Note:

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

  • Note: We DO NOT support the use of BMI because it is NOT a reliable indicator of health. At the same time, we may use the codes for “overweight” or “obese” so that you'll hopefully get some insurance coverage/reimbursement.

• We always code your visit using preventative coding (if applicable) to maximize the number of visits you receive from your insurance carrier. However, if you ONLY have a medical diagnosis (for example: IBS, and you are not “overweight” or have CVD risk factors), your insurance may impose a cost-share for your visit either in the form of a deductible, co-pay or co-insurance.

Question 5: Do I have a cost-share for my nutrition visits?

• Is there a deductible? What is the deductible? How much has been met?

• Is there a copay? How much is the copay?

Note:

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

• We will always bill under your insurance policy’s plan under your preventative benefits if your plan allows. With that being said, if you have preventative benefits, there is often NO cost share for you associated with the visit. Once again, this is something you do want to ask prior to your visit.

• In the event you have a cost-share, we will initially bill your insurance company directly. Once we receive the EOB describing your responsibility as the patient, we will bill the credit card on file for the amount noted under ‘patient responsibility’.

• For most insurance companies, dietitians are considered a specialist. Therefore, your specialist copay is applicable and is payable at the time of service. This information is often apparent on the front of your actual insurance card. However, often because we bill your insurance with preventative counseling, the co-pay is often not applicable.

• We generally wait for the claim to be processed to determine whether or not you have a copay and then charge the credit card you have on file with us the co-pay amount.

Tips:

• Avoid calling on Monday

• Call early in the morning or later in the day - add to your calendar if that’s helpful

• Have all of your information ready (i.e., insurance card)

Checking Out-of-Network Benefits

We're not in-network with all insurances, but if you have out-of-network nutrition insurance benefits, we can provide you with a superbill receipt to submit to your insurance company. You may get full or partial reimbursement from them.

This varies depending on the insurance company and the specific plan you have. Many of our clients who do have out-of-network benefits have had success getting partial or full reimbursement, or at least have it put towards their deductible if they have one.

Steps to Check Your Coverage:

1. Call the phone number for customer service, which is usually located on the back of your insurance card - ask to speak to the benefits department. If your employer provides your plan, your HR department may be able to call on your behalf.

2. Ask if Medical Nutrition Therapy (MNT) is a covered out-of-network benefit based on your plan. The procedure codes we use for MNT are: 97802 (initial assessment) and 97803 (follow-up). Ask them if coverage is dependent on your diagnosis. You may want to ask if there are any benefits for “preventative Z codes.” If so, ask which Z codes and what the requirements are.

3. If there is an MNT benefit, ask if there are any restrictions. For example, a limit of visits, having to use a certain practitioner, etc. Ask if your benefits are subject to your deductible, coinsurance, out-of-pocket max, etc. If your insurance company says that MNT is a benefit, be sure to document the date, every detail of information from the call, a reference number, and who you spoke with. Ask them to send you the information in writing.

4. If there is an MNT benefit, ask how you would submit superbills to get reimbursement.

Tips:

• Avoid calling on Monday

• Call early in the morning or later in the day - add to your calendar if that’s helpful

• Have all of your information ready (i.e., insurance card)

• Collect the name of the representative, call reference number, and a callback number/the number you are being transferred to before you end the call

Note: You may be able to have the MNT benefits applied to the “in-network” benefit side of your insurance plan if they do not have a registered dietitian in their network or if you have an eating disorder and they do not have a registered dietitian who is a Certified Eating Disorder Dietitian (CEDRD). When insurance companies agree to cover an out-of-network practitioner under the “in-network” benefits, this is often called Gap coverage. You may also be able to request a single case agreement for MNT depending upon your plan and diagnosis. Should you obtain a single case agreement or GAP coverage, we will require written documentation and information on copay, deductibles, and how the insurance company would like to be billed for services.

If you have any questions after verifying your benefits, we are happy to help! Please email us and we’ll get back to you within 48 business hours.

A superbill is a document I may provide to you for potential partial or full insurance reimbursement. You pay for your appointment up-front, and then submit the superbill to your insurance company. 

I highly encourage all clients to contact your insurance company and ask about coverage for medical nutrition therapy.