Credentialing 101
Platform that streamlines credentialing process by allowing providers to create a comprehensive profile to share with multiple health plans.
What is CAQH?
A formal request for payment by a healthcare provider to an insurance company.
What is a claim?
This CPT code is used for initial nutrition assessment and intervention session lasting 15 minutes?
What is 97802
CMS covers this nutrition service for diabetes or kidney disease with a doctor’s referral.
What is Medical Nutrition Therapy (MNT)?
This term refers to the process of negotiating better payment rates with an insurance company.
What is contract negotiation?
RDN must apply for this identification number, required for billing before becoming credentialed with insurance company
What is an NPI (National Provider Identifier)?
This term refers to an entity that pays for healthcare services.
What is a payer?
This ICD-10 code is used for diagnosing “obesity due to excess calories.”
What is E66.01?
Many private insurers often require this documentation to cover nutrition counseling.
What is a qualifying diagnosis?
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 codes?
A RDN is considered this in the healthcare system?
What is a provider?
CPT code that represents a 15-minute, face-to-face follow-up session for medical nutrition therapy
What is 97803?
Dietitians struggle with CMS reimbursement because they’re not classified as these providers.
What are "recognized providers"?
Form of RDN documentation to use to ensure proper reimbursement and compliance.
What is a SOAP/ADIME note?
RDNs establishing a private practice must choose a business structure such as a 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?
The governing agency that oversees reimbursement?
What is CMS?
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?
When an insurance company refuses to process a claim due to errors.
What is a rejection?
This CPT code is used for group counseling or education services, typically for MNT in a group setting.
What is 97804?
This insurance step involves requesting approval for non-covered nutrition services.
What is prior authorization or a coverage appeal?
Some insurance plans cover telehealth MNT under this policy expansion due to COVID-19.
What is parity law?