1. TO INSURANCE COACHING!!!
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2. COMPASSION*WORKS MEDICAL
INSURANCE COVERAGE
FOR MEDICAL FOODS
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YOUR RESCUE FOR COVERAGE!!

3. INTRODUCTION
Raenette Franco, CEO, CBCS
Certified Medical Biller Coder Specialist
and Patient Advocate
Founder of
Compassion*Works Medical, LLC
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Disclosure: This presentation is presented for the NPKUA insurance coaching
program and created by Compassion Works Medical, LLC®. The information
provided is not related and/or currently in any conflict of interests bounded by outside
business breaching.

4. THE GOAL!
Covered
Benefit
?
Medically
Necessary
?
Processed
Correctly
?
COVERED!

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5. STEPS TO INSURANCE COVERAGE FOR
MEDICAL FOODS
 Understanding your insurance coverage and policy.
 Gap exceptions/Out of network referrals.
 Assigned case manager from your insurance carrier.
 Following State mandates for fully insured policies.
 Medical food exclusion removals from employers.
 Tools and Resources.
 Insurance terminology.
 Medicare and Medicaid advice.
 Understanding EOB’s.
 Difference between Medical Food benefits
and Pharmacy benefits.
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6. UNDERSTANDING YOUR INSURANCE
COVERAGE AND POLICY (PART 1)
 What is Creditable Coverage? Creditable Coverage
provides policy guidance and benefit information from
any public or private health insurance or health benefits
plan, whether insured or self-insured.
 Read through your Creditable Coverage policy for an
accurate description of medical food/formula benefits
before calling your insurance carrier for questions.
 Key words: ENTERAL, MEDICAL FOODS, NUTRITION,
METABOLIC
 HCPCS Codes: B4155, B4157, B4162, B9998, S9435
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7. UNDERSTANDING YOUR INSURANCE
COVERAGE AND POLICY (PART 2)
 In-network: Providers that participate with your
plan.
 Out-of-network: Providers that do not participate
with your plan.
 Tip: Staying inside your network means smaller
copays and full coverage. If you choose to go
outside your network, you'll have higher out-of-
pocket costs, and not all services may be
covered. 7

8. UNDERSTANDING YOUR INSURANCE
COVERAGE AND POLICY (PART 3)
 Deductible: Amount that you must pay before
the insurance kicks in.
 Out-of-Pocket: A predetermined amount of
money for a chance to increase your insurance
to 100%. It can be a bit confusing with the
deductible. The good news is that you don’t have
to meet any amount before your coverage kicks
in. Sometimes confused with deductible.
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9. UNDERSTANDING YOUR INSURANCE COVERAGE AND
POLICY (PART 4)
 What is a Pre-certification also known as
Prior authorization?
 Pre-certification serves as a utilization
management tool, allowing payment for
services and procedures that are
medically necessary, appropriate and
cost-effective without compromising the
quality of care to you.
 Pre-certification for medical foods must
be approved before your insurance will
cover.
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10. UNDERSTANDING YOUR INSURANCE
COVERAGE AND POLICY (FINAL PART)
 Questions and support?
 Compassion*Works Medical together with
the National PKU Alliance can support you
through our insurance coaching and patient
advocacy program.
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11. 11
HOLDING HANDS TO THE NEXT STEPS
“GAP EXCEPTIONS AND ASSIGNED CASE MANGERS”

12. GAP EXCEPTIONS/OUT OF NETWORK REFERRALS
 What is a Gap Exception? It is asking permission
from your insurance carrier to use a particular
provider that is out-of-network and getting the same
benefits as the in-network level.
 How can I request for a Gap Exception? Usually
your out-of-network provider will make the request. It
is based on no other comparable providers that can
provide the requested service within 30 miles of your
residence proximity.
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13. ASSIGNED CASE MANAGER FROM YOUR
INSURANCE CARRIER
 A system of coordinating medical services to *treat a
patient, *improve care and *reduce cost. A case manager
coordinates health care delivery for patients.
 How do I request for an assigned case manager from
my insurance carrier for my medical foods?
 Answer: Contact member services then ask for the
utilization management department. Once you’re
connected, ask for an assigned case manager and
explain that you have an inborn error of metabolism
disease and need long term assistance.
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14. HOLDING HANDS TO THE NEXT STEPS
“FOLLOWING STATE MANDATES &
MEDICAL FOOD EXCLUSION REMOVAL”
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15. FOLLOWING STATE MANDATES FOR FULLY INSURED
POLICIES (PART 1)
 How do I know if my State has a mandate?
 Answer: You can check the NPKUA website to
determine if your state has a mandate.
http://www.npkua.org/TakeAction/StateCoverage.as
px.
 Every state has their own laws. Few have
deductible and co-pay waivers that helps a great
deal without paying out of pocket to get coverage
before insurance kick in! Some have an annual
maximum (i.e. $2,500, etc.).
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16. FOLLOWING STATE MANDATES FOR FULLY
INSURED POLICIES (PART 2)
 If I am in a state with a deductible waiver, how can I
get my insurance carrier to ride-off the deductible?
 Answer: The good news is that some insurance
carriers already follows their mandate After
verification of benefits they will make a note on your
policy and create a rider.
 What is a Rider?
 Answer: A rider is an amendment to
an insurance policy.
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17. FOLLOWING STATE MANDATES FOR FULLY
INSURED POLICIES (FINAL PART )
 If a policy is unaware of your state mandate, you
should send them a copy of the law to create any
riders. (i.e. deductibles, medical exclusions, etc.).
 Advice: Print out a copy of your state mandate
from the NPKUA website and keep for insurance
assistance.
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18. 18
HOLDING HANDS TO THE
NEXT STEPS
“INSURANCE TERMINOLOGY
AND MEDICAL FOOD
EXCLUSION REMOVAL”

19. WHAT IS THE PROPER INSURANCE
TERMINOLOGY?
 Without knowing the proper insurance terminology,
understanding your insurance coverage for Medical
Foods/Enteral Formula can be confusing and
frustrating.
 Let’s learn a few simple questions to ask and
words…….
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20. HOW DO I COMMUNICATE WITH MY
INSURANCE CARRIER?
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 What is my coverage for Medical
Foods and Enteral Formula?
 I have service codes that I will like to
check? (B4157, B4162 (pediatric),
S9434, S9435). A service code also
known as HCPCS/CPT code is the
description of the medical food
service.

21. HOW DO I COMMUNICATE WITH MY
INSURANCE CARRIER?
 What is my deductible (if any)?
 Has my deducible been met?
 What is the allowed amount on my
plan?
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22. HOW DO I COMMUNICATE WITH MY
INSURANCE CARRIER?
 Is my plan fully insured or self funded? This could
help to determine when to use your state mandated
law (fully insured plans).
 What is my out-of-pocket? This could help to
increase your benefit coverage to 100%.
 Is there any Exclusion to the service codes or
service? If any, this is a good time to use your state
mandated law.
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23. HOW DO I COMMUNICATE WITH MY
INSURANCE CARRIER?
 May I have a reference number for this
call?
 IMPORTANT **** WHAT IS THE BENEFIT
CUSTOMER SERVICE NAME? WHAT IS THE
REFERENCE NUMBER FOR THE CALL?
 You may get different answers from your
providers verification. Always contact your
provider to compare answers.
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24. INSURANCE WORDS
 Medical Foods and Enteral Formula: Are the
same description with different words.
 Service Codes: A description of service in a
numerical/alphabetical format.
 Pre-certification also know as prior authorization:
An approval from your insurance company that
service are medically necessary and covered (i.e.
#1234567).
 Deductible: An amount of money that needs to be
met before your insurance pays.
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25. INSURANCE WORDS
 Fully Insured Plan: When you may your own
premium or a percentage from your employer.
 Self-funded Plan: When your employer pays for
your benefits or if you have Medicaid/Medicare
(state/federal funded plan).
 Out-of-Pocket: Sometimes confused with
deductible. It’s when you pay for medical expenses
until you reach your insurance dollar amount. It
increases your co-insurance to 100% (if any). Does
not have to be met before insurance pays their part.
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26. INSURANCE WORDS
 Exclusions: Items or conditions that are not
covered by the general insurance contract.
 Allowed Amount: Maximum amount on which
payment is based for covered health care services.
This may be called “eligible expense,” “payment
allowance" or "negotiated rate." If your provider
charges more than the allowed amount, you may
have to pay the difference.
 Lets talk a little more about allowed amount……
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27. MORE ON ALLOWED AMOUNT WITH HEALTH
INSURANCE PLANS…..
 Example of an allowed amount: All of us with
health insurance think that 100% is covered in full,
or even 80%, 70%, 60%, 50% we think they pay the
full percentages. Right??
 The answer is “NOT Typically”, this is how it works
with out us knowing. Example: The Allowable
Charge is typically a discounted rate rather than
the actual charge and considered payment in full
from your insurance company and the provider.
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28. MORE ON ALLOWED AMOUNT WITH HEALTH
INSURANCE PLANS…..
 It may be helpful to consider an example: You have
just purchased your medical food. The total charge for
the medical food comes to $100. If the provider is a
member of your health insurance company's network of
providers (in-network), they may be required to accept
$80 as payment in full for the medical food - this is the
Allowable Charge.
 In-network providers: Your health insurance company
will pay all or a portion of the remaining $80, minus any
co-payment or deductible that you may owe. The
remaining $20 is considered provider write-off. You
cannot be billed for this provider write-off.
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29. MORE ON ALLOWED AMOUNT WITH HEALTH
INSURANCE PLANS…..
 Out of network providers: If, however, the
provider you purchased your medical foods from is
not a network provider then you may be held
responsible for everything that your health
insurance company will not pay, up to the full
charge of $100. This is your responsibility!
 You can check the charges, allowed amount and
your patient responsibility from your EOB
(Explanation of Benefits). A statement, “not a bill”
provided by your insurance company. Or you can
ask for a copy from your provider.
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30. HOW TO READ AN EXPANATION OF
BENEFITS (EOB)?
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31. EOB PROCESSING CIRCLE
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32. THIS BRINGS US TO OUR NEXT STEP MEDICAL
EXCLUSION REMOVALS AND
THE DIFFERENCE BETWEEN MEDICAL VS.
PHARMACY BENEFITS……
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33. MEDICAL FOOD EXCLUSION REMOVALS FROM
EMPLOYERS
 My insurance is not covering my formula because
there is an exclusion. How do I get my exclusion
removed?
 Answer: Usually your exclusions come from your
employers contracted plan with your insurance
company. You will have to present a letter of
medical necessity (LOMN) and a medical food
exclusion removal request letter to your Human
Resource Department for assistance.
 For Federal and State plans, exclusion removals
are a bit complex. You should seek assistance from
a certified insurance advocate. 33

34. MEDICAL FOOD EXCLUSION REMOVALS TOOLS
 LOOKING FOR HELP AND TOOLS???
 Please find template letters for medical food exclusion
removal request letters and letter of medical necessities on
the NPKUA website.
http://www.npkua.org/Resources/InsuranceCoverage.asp
x.
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35. DIFFERENCE BETWEEN MEDICAL BENEFIT
VS. PHARMACY BENEFIT
 Medical benefits for Enteral Formula/Medical Foods
use a HCPCS code (i.e. B4157, S9435). Pharmacy
benefits uses NDC codes to identify a particular
“product” not a medical service such as a HCPCS
code.
 Depending on the patient’s insurance plan, some
may have enteral formula/medical foods covered
only under medical, some only under pharmacy or
both. Some pharmacies bill both DME & Pharmacy
covered items. Some just cover pharmacy benefits.
Nothing here ostracizes a medical benefit or
pharmacy benefit.
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36. DIFFERENCE BETWEEN MEDICAL BENEFIT
VS. PHARMACY BENEFIT
 It’s important to understand the difference. It can be
a bit confusing to patients and some clinical
professionals.
 This is one of the reasons why it is good to verify
both benefits to choose the most affordable benefit
choice!
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37. INSURANCE ADVOCATE SUPPORT
 For certified insurance advocate support:
Compassion*Works Medical and the NPKUA
INSURANCE COACHES PROGRAM.

The NPKUA has a new resource to help guide you
through the difficult process of obtaining medical
foods coverage. The NPKUA Insurance Coaches
Program, led by Raenette Franco, CEO, CBCS of
Compassion*Works, is a place that can help!
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38. GOT MEDICARE OR MEDICAID?
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39. DO YOU HAVE MEDICAID OR MEDICARE?
HERE ARE SOME TIPS!
 My Medicaid and/or Medicare plan does not cover
my formula?
 Answer: First do you have a straight plan from the
state? If so, the best way to get covered under your
plans would be to enroll into a Managed Medicaid
or Medicare plan. A supplement plan is not the
same as a managed plan. Supplement plans follow
the same rules with the straight plans.
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40. WHAT IS A MANAGED MEDICAID/MEDICARE
PLAN?
 The term managed care or managed health care is
used in the United States to describe a variety of
techniques intended to reduce the cost of providing
health benefits and improve the quality of care.
 A managed Medicaid or Medicare plan is the middle
man between your straight care plan and the managed
care plan (i.e. Aetna, Humana, United Health Care, Blue
Cross Blue Shield, etc.).
 It offers special needs and leniency towards medical
food coverage than a straight state plan.
 Most state Medicaid plans pushes to a managed care
plan. Medicare is your choice. However, best choice! 40

41. HOW DO I FIND A MANAGED CARE PLAN FOR
MY STATE?
 Managed Medicare plans; use Medicare Plan
Finder at https://www.medicare.gov/find-a-
plan/questions/home.aspx. Or simply call member
services listed on the back of your Medicare card.
 Managed Medicaid plans; call member services
listed on the back of your Medicaid card.
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42. HOW TO GET HELP….
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Simple Steps of how to get help provided by Compassion Works
Medical . Trained and managing the NPKUA volunteer insurance
coaching program.
1. For one on one coverage support and more coverage
information, please contact the NPKUA Reimbursement
Coaches. Call NPKUA to see if there is a Coach in your state.
2. Please visit the NPKUA website http://www.npkua.org
3. Contact Compassion*Works Medical, LLC at
(973) 832-4736 or email: support@compassionworksmrs.com
We want to help you get there!

43. HOLDING HANDS FOR PATIENT ADVOCACY SUPPORT
Compassion*Works Medical mission is to provide
Medical Food Coverage/Reimbursement and true patient
advocacy support to clinics and people with rare
genetic diseases.
We are the first responders for coverage support!
Together with we can go a long……way!
You are not alone. We are here to hold your hand all the
way through the difficult tasks of medical food
coverage!
Contact: Raenette Franco, CEO, CBCS
raenettef@compassionworksmrs.com
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The first habit of the
heart: We’re all in this
together!