Note: If Medicare doesn't pay for D. Medical Nutrition Therapy below, you may have to pay. Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for the D. Medical Nutrition Therapy below.
|D.||E. Reason Medicare May Not Pay:||F. Estimated Cost|
|Medical Nutrition Therapy||Non Covered Diagnosis||$125 for initial visit $75 for followup|
G. Options: Check only one box. We cannot choose a box for you.
OPTION 1. I want the D.___________ listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.
OPTION 3. I don't want the D.___________ listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.
H. Additional Information:
This notice gives our opinion, not an official Medicare decision. If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048). Signing below means that you have received and understand this notice. You also receive a copy.
CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call 1-800-MEDICARE or email AltFormatRequest@cms.hhs.gov