Aetna recently updated its preventive service guidelines for nutrition counseling.
Under its current policy, preventive nutrition counseling is covered for patients with certain qualifying health conditions, including:
Diabetes
High cholesterol or hyperlipidemia
Hypertension (high blood pressure)
Obesity (a BMI of 30 or higher)
Certain pregnancy-related health conditions, including high-risk pregnancy, high blood pressure during pregnancy, pregnancy with twins or multiples, certain fetal health concerns, or obesity affecting pregnancy
If you have one of these conditions, we often need documentation from your physician or another medical provider so we can bill your appointments with the appropriate diagnosis code and maximize your insurance coverage.
What to do if you have one of these conditions
1. Obtain documentation of your diagnosis.
Ask your doctor for documentation of your diagnosis, or download it from your patient portal. Visit notes, medical records, or physician referrals typically satisfy this requirement, as long as they show one of the qualifying conditions listed above.
Including all applicable ICD-10 diagnosis codes in your documentation helps us bill your appointments accurately. To support preventive coverage, your documentation must show one of the qualifying conditions listed above.
You can use this sample referral template to make sure your documentation includes the necessary information.
2. Send your documentation to Fay.
You can submit your documentation using either of the following methods:
Upload it to the Docs & Forms section of your Fay account by following these steps.
Ask your doctor to fax it to us at +1 (329) 204-3362.
3. We’ll take it from there.
Once we receive your documentation, we’ll resubmit any past appointments affected by this change to Aetna for reprocessing and let you know if your cost changes. Your documentation will also apply to future appointments, so you only need to send it once.
What this means for your cost
If Aetna covers your appointment as preventive care, you can expect to pay $0 out of pocket within standard plan visit limits. If you have reached your annual visit limit, you may be still subject to out of pocket cost.
If your appointment is not covered as preventive care, it may be subject to the cost sharing established by your specific Aetna plan, including a deductible, copay, or coinsurance.
We recommend calling the number on the back of your insurance card for more information about your specific coverage or to confirm your annual visit limit.
If the Aetna rep advises that certain codes are needed to bill as preventative, we still need documentation of those underlying codes, as the codes provided correspond to the qualifying health conditions listed above.
Coverage for other conditions
If you have a condition other than the ones listed above, it will fall under medical nutrition therapy, not preventative. However, any diagnosis documentation you have available may still optimize your coverage.
For eating disorders specifically, please share any signed documentation of your condition so we can work with your plan to confirm coverage.