Neocate

Reimbursement Support

• WIC
• Medicaid
• Private Insurance
• Sample Insurance Letters
• Neocate Assistance Program (NAP)
• Definitions
• Why do You Need to Provide Reimbursement Codes?
• Hints and Tips for Successful Reimbursement
• HCPCS codes
• Reimbursement Legislation

Reimbursement of Medical Foods and Exempt Infant Formulas

At Nutricia, we know that reimbursement of medical foods and exempt infant formulas is an important piece in families’ lives, influences medical decisions and contributes to better health and diet compliance.

Several government programs as well as some private insurance companies provide reimbursement of Neocate products. The information below outlines some of the various programs that often assist with reimbursement of Neocate.

WIC

The Women, Infants and Children Nutrition Program (WIC) is a government program designed to assist families with nutritional needs. Neocate is generally reimbursed by most state WIC programs based on medical need and when ordered by a physician. To find out if you are eligible to receive Neocate through your local WIC program, contact your nearest community health department.

Learn more about WIC.

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Medicaid

Medicaid is a combination state and Federal government run program. Each state establishes its own guidelines regarding medical foods and other nutritional products. To learn if you are eligible for coverage of Neocate through your state Medicaid office, contact your nearest community health department.

Learn more about Medicaid.

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Private Insurance

Some private insurers provide coverage for Neocate products. Private insurance coverage can vary state-by-state and plan-by-plan. Some states have laws requiring the private insurers in their state to cover Neocate products. View the reimbursement legislation section of this page for a list of states with such laws.

If you do not live in one of these states and wish to find out if your private insurance company will cover the cost of Neocate, contact the Customer Service Department number found on your insurance card. For additional reimbursement support, please contact our Nutrition Services Department by calling 1-800-365-7354 or the Neocate Reimbursement Helpdesk at neocateinsurance@shsna.com. We will be happy to assist you!

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Sample Insurance Letters
For your convenience, Nutricia has several medical necessity letters that can be easily downloaded for your physician’s signature. The following sample reimbursement letters are intended to help you gain insurance coverage. Please contact your physician to complete the missing information and individualize the letters according to your specific needs.

Simply click the appropriate product below to download the Word file of each sample letter.

• Neocate Infant DHA and ARA
• Neocate Infant
• Neocate One+
• Neocate Junior
• Neocate Junior with Prebiotics
• Neocate Nutra
• E028 Splash
• Pepdite Junior

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Neocate Assistance Program (NAP)

The NAP is designed to assist economically/ financially disadvantaged infants obtain Neocate infant products. The NAP is not designed to replace other available financial resources nor remove all financial responsibility from recipients in every instance. Applicants must be legal residents of the U.S. and not have third party coverage for nutritional therapy. The Neocate Assistance Program should be considered the payer of last resort. For additional information including application forms, please contact 1-800-Neocate.

Click here to download an application.

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Definitions

Exempt Infant Formula:
Food and Drug Administration, HHS

21 CFR Ch. 1 (4-1-97 Edition)
§ 107.50
Subpart C - Exempt Infant Formulas

(c) Infant formulas not generally available at the retail level. (1) These exempt infant formulas are not generally found on retail shelves for general consumer purchase. Such formulas typically are prescribed by a physician, and must be requested from a pharmacist, or are distributed directly to institutions such as hospitals, clinics, and State or Federal agencies. Such formulas are also generally represented and labeled solely to provide dietary management for specific diseases or conditions that are clinically serious or life-threatening and generally are required for prolonged periods of time.

Medical Food:
Food and Drug Administration, HHS
21 CFR Ch. 1 (4-1-95 Edition)
§ 101.9

(8) Medical foods as defined in section 5(b) of the Orphan Drug Act (21 U.S.C. 360ee(b)(3)). A medical food is a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation. A food is subject to this exemption only if:

1. It is a specially formulated and processed product (as opposed to a naturally occurring foodstuff used in its natural state) for the partial or exclusive feeding of a patient by means of oral intake or interal feeding by tube;
2. It is intended for the dietary management of a patient who, because of therapeutic or chronic medical needs, has limited or impaired capacity to ingest, digest, absorb, or metabolize ordinary foodstuffs or certain nutrients, or who has other special medically determined nutrient requirements, the dietary management of which cannot be achieved by the modification of the normal diet alone;
3. It provides nutritional support specifically modified for the management of the unique nutrient needs that result from the specific disease or condition, as determined by medical evaluation;
4. It is intended to be used under medical supervision; and
5. It is intended only for a patient receiving active and ongoing medical supervision wherein the patient requires medical care on a recurring basis for, among other things, instructions on the use of the medical food.

From the Office of the Federal Register, National Archives and Records Administration.

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Why Do You Need To Provide Reimbursement Codes?

Third-party payers such as Medicaid and HMOs may reimburse for the cost of Medical Foods and Exempt Infant Formulas. To process claims, payers/insurance companies require a reimbursement code to identify the nutritional product or category.  Some states have enacted legislation, which require that reimbursement be provided based on the patient’s diagnosis. Your doctor’s office may have more information regarding reimbursement in your state.

Claims are usually processed one of two ways:

• A code is used to identify the product through the HCFA Common Procedure Coding System (HCPCS) or
• The National Drug Code (NDC) system.

Most states will use one of these systems to classify products for reimbursement purposes.  Individual insurance plans will also choose one of these systems to reimburse patients for nutritional products.
In addition, there are diagnostic codes, so called ICD-9 codes, which identify the disease of the patient and may further help in getting reimbursement.

It is therefore important to supply as much information as possible to your insurance company and to make sure you are providing accurate and complete information according to the guidelines of your insurance company.

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Hints and Tips for Successful Reimbursement

What your physician can do:

• Provide a letter of medical necessity from the physician including the following facts:
• Detailed diagnosis including but not limited to growth charts and documentation about the progress of the patient
• Lab results where applicable
• Argue that nutritional therapy is more cost effective and in many cases even medically more effective than other alternatives (e.g. tube feeding)
• The more detailed the information the better the chances for reimbursement

What you can do:

• Make sure your submission is complete and according to your insurance company’s guidelines
• Be persistent
• Consider providing the following:
• Letter of medical necessity
• Medical documentation
• Definition of Medical Food and Exempt Infant Formula
• Ask to speak to a Nurse Case Manager in your insurance company and don’t stop with Customer Service
• Utilize all the appeals levels, 1st, 2nd, 3rd, Grievance.  Write down every person that you have spoken to and what they have said on each date.
• Find out the process for utilizing your mail order prescription program (if you have one).  Try to get it through your mail order benefit by following the sample procedure you would for other medications.
• Use FSA (Flexible Spending Account) dollars to pay for the formula (if your employer has one).

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HCPCS Codes

Some insurance companies and state programs that cover our products require a reimbursement or Healthcare Common Procedure Code (HCPC). These codes are listed here for your convenience.

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Reimbursement Legislation

The following states now require that insurance companies reimburse families for Neocate. The details of each law are different, so click your state below to find out more.

Here at Nutricia, we are all very excited each time a state passes a bill that will provide families with some economic relief. However, we know how difficult the reimbursement process can be, even with legislation in place.

Here are some key things you’ll want to keep in mind if you live in a state with legislation:

Effective Date – Many times it will take several months from the date a bill is passed to the date it becomes effective. Make sure to carefully review the bill for your state to know when it goes into effect.

Date You Receive Coverage – The date you are eligible for coverage is dependent on when your insurance plan renews. This varies with every plan and can be up to a year after the effective date.

Medical Conditions – In some states the legislation only requires coverage of amino acid-based formulas for the diagnosis and treatment of certain medical conditions (i.e. eosinophilic gastroenteritis or multiple food protein intolerance). It is important to understand the limitations of the bill and your child’s condition prior to working with your insurance company.

Once you’ve reviewed and understand the legislation for your state, we encourage you to do the following to ensure you receive coverage as soon as you are eligible:

• Contact your insurance company to find out when your specific plan renews and when you’ll be able to start being reimbursed for Neocate.
• Ask your insurance company what documentation you need to provide them (i.e. do you need a letter of medical necessity from your doctor).
• Share the bill with your doctor and work with your physician early on to secure the necessary documentation.

Get Involved

These important laws came to be thanks in large part to the many parents and families who got involved in the legislative process, sharing their stories with their communities and elected officials.

To learn how you can get involved in your state, visit www.childrensmagic.org

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