Credentialing 101
Platform that streamlines credentialing process by allowing providers to create a comprehensive profile to share with multiple health plans.
What is CAQH?
This term refers to an entity that pays for healthcare services.
What is a payer?
This CPT code is used for initial nutrition assessment and intervention sessions lasting 15 minutes?
What is 97802
The governing agency that oversees reimbursement.
What is CMS?
This term refers to the process of negotiating better payment rates with an insurance company.
What is contract negotiation?
Before becoming credentialed with an insurance company, an RDN must first apply for this unique identification number, required for billing.
What is an NPI (National Provider Identifier)?
A formal request for payment submitted by a healthcare provider to an insurance company.
What is a claim?
This ICD-10 code is used for diagnosing “obesity due to excess calories.”
What is E66.01?
CMS covers this nutrition service for diabetes or kidney disease with a doctor’s referral.
What is Medical Nutrition Therapy (MNT)?
The best way to ensure payment is to obtain this from the insurance provider before seeing a patient.
What is verification of benefits?
When reviewing an insurance contract, an RDN should examine these codes that determine how services are billed and reimbursed.
What are CPT/Procedure codes?
When an insurance company refuses to process a claim due to errors.
What is a rejection?
This CPT code represents a 15-minute, face-to-face follow-up session for medical nutrition therapy provided by an RDN.
What is 97803?
Many private insurers often require this documentation to cover nutrition counseling.
What is a qualifying diagnosis?
Form of RDN documentation used to ensure proper reimbursement and compliance.
What is a SOAP/ADIME note?
RDNs establishing a private practice must choose a business structure (e.g. LLC) and register it with this government entity.
What is the appropriate state business registration office (e.g., Secretary of State’s Office)?
When a claim does not provide payment due to coverage issues or medical necessity.
What is a denial?
This ICD-10 code is commonly used for a diagnosis of essential hypertension?
What is I10?
RDNs struggle with insurance reimbursement because they’re not classified as these providers.
What are “recognized (credentialed) providers”?
This term refers to the percentage of the service cost that the patient must pay out-of-pocket.
What is coinsurance?
This form is required by insurance companies to verify a provider’s taxpayer identification information.
What is a W-9 Form?
A RDN is considered this in the healthcare system?
What is a provider?
This CPT code bills in 30-minute units for 2 or more individuals.
What is 97804?
This insurance step involves requesting approval for non-covered nutrition services.
What is prior authorization (coverage appeal)?
Some insurance plans cover telehealth MNT under this policy expansion due to COVID-19.
What is parity law?