Insurance Worksheet for Nutrition Counseling

CHECKING INSURANCE BENEFITS
FOR MEDICAL NUTRITION THERAPY
We recommend that you verify your benefit coverage prior to scheduling. Included below is a
list of questions you can use to verify coverage with your insurance company.
Here are a few things you’ll need to know for your insurance verification:
1. The CPT (billing) code for Medical Nutrition Therapy is 97802
2. We are a hospital-based program:
a. Because we are hospital based, your visit will not be billed under an individual
provider; it will be billed as an outpatient hospital visit with EvergreenHealth
Medical Center
b. Our Tax ID number is 91-0844563
3. You may need to know your specific ICD10 diagnosis code for accurate benefit
information. Please ask the provider who is referring you for your specific diagnosis
code
Does my deductible
apply?
If Yes, what amount has
been met?
Date of Call:
Name of the person you
spoke with:
Is MNT a covered
benefit for me?
(see CPT code above)
How many visits or
hours are authorized per
year?
What is the percentage
of allowable paid?
Is pre-authorization
required?
Does a copay apply?
Yes / No
Yes / No
If Yes, how much?
Confirmation Number
(if applicable):
Yes / No
Once you have verified coverage, please call us at 425.899.3008 to get scheduled.
If you do not have coverage but would like to self-pay, please call our Business Office at
425.899.1600 for payment options.
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EvergreenHealth Diabetes Education and Nutrition Services | 12303 NE 130 Lane, Coral 325, Kirkland WA 98034
425.899.3008 p | 425.899.2663 f | [email protected] | evergreenhealth.com/diabetes