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PROVIDER RESOURCES

How Pathway Plus Works

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  • You examine and recommend a treatment plan to your patient(s).

  • You contact Pathway Plus to help confirm the patient’s healthcare coverage for the recommended Abbott Nutrition product. Pathway Plus will need certain information in order to complete this service. (See below for the required enrollment forms.)

  • Pathway Plus provides a written summary of benefits to you and verbally relays coverage results and any out-of-pocket costs/co-pays to the patient.

Enrollment forms

Pathway Plus can contact your patient’s insurance plan to verify if they have insurance coverage for Abbott Nutrition products. Specific information outlined on the enrollment form is required from you to complete this service. Please select the form that describes the product you are recommending. (Select the General form if the product is not listed below.)

Sample Medical Necessity Letters

Some insurance plans may require a Letter of Medical Necessity to help provide the medical justification for potential insurance benefits. Pathway Plus provides sample letters for some products. Please select the Sample Letter that describes the product you are recommending.

Prior authorization tips

Prior authorization requirements vary among insurance plans. We have listed below some of the forms and documents you might need for an insurance plan to obtain prior authorization. This list does not guarantee prior authorization approval.

  • A Letter of Medical Necessity

  • The patient’s insurance plan information or copy of their insurance card (front and back)

  • Any supporting documentation including:

    • The insurance plan’s prior authorization form
    • Relevant patient history and physical findings
    • Chart notes from the healthcare provider
    • Test and lab results
    • Hospital admission/emergency department notes (if applicable)
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Billing codes

Codes are required by payers to identify the nutrition product or category of products. Abbott Nutrition products have HCPCS codes and NDC-format codes.

Click below for a full list of codes for Abbott Nutrition products.

GET THE CODES

Pathway Plus can assist with the following programs:

  • Medicare 

    • Medicare is the federal health insurance program for:
      • People who are 65 or older
      • Certain younger people with disabilities
      • People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD)
    • The different parts of Medicare help cover specific services: 
      • Medicare Part A (Hospital Insurance)
        • Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home healthcare.
      • Medicare Part B (Medical Insurance)
        • Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services. Medicare Part B may cover enteral nutrition when fed through a feeding tube.
      • Medicare Part C (Medicare Advantage)  
        • A Medicare Advantage Plan (like an HMO or PPO) is another Medicare health plan choice you may have as part of Medicare. Medicare Advantage Plans are offered by private companies approved by Medicare.
      •  Medicare Part D (prescription drug coverage)
        • Helps cover the cost of prescription drugs (including many recommended shots or vaccines).

  • Medicaid

    • Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. Each state Medicaid program establishes its own criteria regarding coverage of nutritional products. Most state Medicaid programs will cover nutritional products when fed through a feeding tube, and many states will cover products consumed orally (swallowing) when specific criteria are met.

  • Private Insurance 

    • Private health insurance refers to health insurance plans marketed by the private health insurance industry, as opposed to government-run insurance programs like Medicare or Medicaid. Coverage varies by plan. Some insurance plans cover nutritional products when the patient’s health condition meets specific criteria. The healthcare provider must provide information supporting the diagnosis, condition, and medical necessity to justify the need for the product. Additionally, some states have insurance mandates that require certain payers to cover nutritional products for certain conditions. These state mandates are all very different. To learn if your insurance plan covers nutritional products, call Pathway Plus at 855-217-0698.

  • Military Healthcare

    • TRICARE is the healthcare program serving uniformed service members, retirees and their families. Abbott Nutrition products may be reimbursed through TRICARE on the basis of medical need when ordered by a healthcare provider.

  • Flexible Spending Accounts (FSAs), Health Savings Accounts (HSAs)

    • Oral nutrition supplements may be covered under FSAs/HSAs if they meet the following criteria: 
      1. Are recommended by a healthcare professional for a specific medical condition that is diagnosed by a physician, and
      2. The plan that manages the member’s FSA/HSA approves the product for coverage.
    • Members should consult their specific plan’s coverage policy for any additional requirements and/or documentation needs.

  • Supplemental Nutrition Assistance Program (SNAP)

    • The Supplemental Nutrition Assistance Program (SNAP) provides nutrition benefits to supplement the food budget of needy families so they can purchase healthy food and move towards self-sufficiency. Most Abbott Nutrition products are available for purchase using SNAP benefits.

  • Women Infants And Children Program (WIC)

    • The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides Federal grants to States for supplemental foods, health care referrals, and nutrition education for low-income pregnant, breastfeeding, and non-breastfeeding postpartum women, and to infants and children up to age five who are found to be at nutritional risk. WIC provides infant formula for babies who are not exclusively breastfed and provides many specialized formulas for infants, women, and children with appropriate medical documentation. Check with your local or state WIC agency to see which Abbott products are available in your state.

  •  Patient Assistance Program

    • When no other coverage options exist, Pathway Plus can assess your eligibility for the Abbott Nutrition Patient Assistance Program

 

To qualify, you must:

  • Reside in one of the 50 states or the District of Columbia and have no healthcare insurance coverage for the requested product

  • Have no access to alternative sources of coverage

  • Meet financial eligibility criteria

  • Require 100% of caloric needs from the requested product

To apply, download the Patient Assistance Program application or call 1-866-801-5657.

 (Not all Abbott Nutrition products are available on the Patient Assistance Program.)

Additional resources

DOWNLOADS

HCPCS codes 

 

Each healthcare provider is ultimately responsible for verifying codes, coverage, and payment policies used to ensure that they are accurate for the services and items provided. Providers should consult with the insurance plan for complete and accurate details concerning documentation for claims. Abbott Nutrition does not guarantee reimbursement by any third-party insurance plan and will not reimburse physicians or providers for claims denied by third-party insurance plans.

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