Insurance or Medicare/Medicaid Reimbursement Information
July 19, 2016
Insurance or Medicare/Medicaid Reimbursement Information
Check to see if your insurance company will reimburse you for oral rehydration to prevent your hospitalization for correcting dehydration, as a hospitalization may be very expensive. Dehydration causes volume depletion, which can result in serious conditions including seizures, hypovolemic shock, kidney failure, swelling of the brain, fainting and delirium and unconsciousness. Untreated, dehydration can cause death. Oral hydration, especially for those with chronic conditions, may be covered. For People over age 50 begin losing the sensation of thirst and may not recognize getting dehydrated until they are already in need of a liter or two. For athletes, dehydration can not only mean a loss of performance of up to 30% but also low endurance, rapid heart rate, elevated body temperature, but also confusion, negative moods and fatigue.
The Center for Medicare and Medicaid Services (CMS) has determined that Medicare HCPCS Codes to bill for DME Medicare Administrative Contractors (DME MAC) are allowable for CeraLyte-50, CeraLyte-70, and CeraLyte-90 with the following HCPCS Codes (effective 9/22/05), and CeraSport and CeraSportEX1 (as of 1/19/09):
B4102 Enteral Formula for adults, used to replace fluids and electrolytes (e.g. clear liquids), 500mL = 1 unit.
or
B4103 Enteral Formula for pediatrics, used to replace fluids and electrolytes (e.g. clear liquids), 500mL = 1 unit.
For more information, call our office at 843.842.2600.
Medicare/Medicaid Reimbursement for CeraLyte: A Step-by-Step “How to Guide”
1. If you also have Primary or Private Health Insurance (for example, HMO, etc.) you will need to get a “Denial Letter” from them stating that they will not cover CeraLyte or CeraSport or CeraSportEX1 reimbursement. This is usually simple to do, either you as the patient or your doctor’s office can contact the Insurance Company’s Member Services Department stating your medical need for CeraLyte or CeraSport or CeraSportEX1 oral rehydration. The Primary Insurance may deny coverage of any rehydration fluids and will thus supply you with the necessary “Denial Letter”. (Note: The worst case scenario at this point is that the Primary Insurance does not deny coverage and pays for the CeraLyte and/or CeraSport ORS).
2. Once you have your “Denial Letter”, specifically stating that your Primary Insurance will not cover CeraLyte (specify which number 50, 70 or 90) or CeraSport or CeraSportEX1. You or your doctor’s office may then present this letter to Medicare/Medicaid along with a letter of “Medical Necessity”, stating that you need CeraLyte or CeraSport for “X” medical condition. Usually these two items are enough to get you approval for Medicaid Reimbursement. For patients with only Medicaid Insurance, Medicaid would require submittal of just the letter of “Medical Necessity” in order to approve reimbursement.
3. Although this process may appear to be rather straight forward, and it can be, it can be long and tedious. It is recommended that you keep good notes of all dates of letters, phone calls, names of people with whom you spoke, etc. Some insurance companies and state agencies may require slightly different information but they will contact you with requests as needed.
*Note: This “step by step” process was sent to Cera Products by families who report needing CeraLyte to avert hospitalization from dehydration, for averting seizures, and volume depletion.
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