Download SAMPLE LETTER FOR NEOVATE INFANT FORMULA

DATE:
______________________________
TO:
______________________________
(Insurance Company)
FROM:
______________________________
SUBJECT:
______________________________
I am requesting insurance coverage and reimbursement for my patient,
___________________________________, for whom I have prescribed the use of
Neocate® Junior (manufactured by Nutricia North America).
I feel that Neocate Junior is a medical necessity and will provide the proper dietary
management for this patient, who has been diagnosed with
__________________________________. Without the use of Neocate Junior, my
patient may experience complications of the condition, which may result in
hospitalization and/or costly parenteral nutrition.
Neocate Junior is an amino acid based nutritionally complete elemental formula. It is
specifically designed for children over one year of age with gastrointestinal impairment
due to milk protein sensitivity or other medical conditions affecting the gastrointestinal
tract. Its unique formulation (100% free amino acids, milk free, gluten free, and soy
protein free) provides complete nutrition and can be the sole source of nutrition. Neocate
Junior has an elemental composition, which requires minimal digestion, thus ideally
suited for patients with compromised gastrointestinal function.
The FDA classifies Neocate Junior as a “medical food” which must be used under
medical supervision and is not sold over the counter or at the retail level. Therefore,
Neocate Junior is only available through a pharmacy or through Nutricia North America
directly (with medical consent). For additional reimbursement codes and information,
please see the reverse side.
Your approval of this request for insurance coverage and reimbursement of the Neocate
Junior would make a significant impact on this patient’s health.
Sincerely,
NEOCATE AND REIMBURSEMENT
Third-party payers such as Medicaid and HMOs will reimburse for the cost of Neocate
Junior. To process claims for Neocate Junior, payers require a reimbursement code to
identify the nutritional product/category. Some states have enacted legislation, which
require that reimbursement be provided based on the patient’s diagnosis.
Claims are usually processed in one of two ways. A code is used to identify Neocate
Junior through the HCFA Healthcare Procedure Coding System (HCPCS), or through
the National Drug Code (NDC) system. Most states will use one of these systems to
classify Neocate Junior for reimbursement purposes. Individual insurance plans will
also choose one of these systems to reimburse patients for nutritional products.
CODING SYSTEMS:
MEDICARE (HCPCS)
Neocate Junior is classified under Code # B4161.
NATIONAL DRUG CODE (NDC)
Neocate Junior is not a drug but is classified by the FDA as a “medical food”, which
requires usage under strict medical supervision. The NDC code for the Neocate Junior
is:
49735-0117-90
Neocate Junior, unflavored
49735-0121-24
Neocate Junior, tropical
49735-0126-90
Neocate Junior, chocolate