Nursing Homes
Not a covered benefit; this includes convalescent, respite or domiciliary care, assistance with activities of daily living or other non-skilled care. Please note care in a skilled nursing facility is different than care in a nursing home.
Nutrition and Diet Counseling
Medical nutritional counseling required in the administration and maintenance of covered medically necessary foods, to include low protein foods, may be covered when medically necessary and appropriate. All other types of medical nutritional and diet counseling are only covered when provided as part of a primary care office visit or under diabetes outpatient self-management training. Nutrition and diet counseling cannot be billed separately when provided as part of a primary care office visit.
Nutritional Therapy
Nutritional therapy is a limited benefit and may be a covered when prescribed for dietary management of a covered disease or condition. A covered disease and/or condition may include: inborn errors of metabolism (IEM), medical conditions of malabsorption, pathologies of the alimentary tract or the gastrointestinal tract, and a neurological or physiological condition. Covered nutritional therapies include: enteral, parenteral and oral nutritional therapy. Additionally, intraperitoneal nutrition therapy is only covered for malnutrition as a result of end-stage renal disease. Any formula listed on the Enteral Nutrition Product Classification List is eligible for TRICARE cost-sharing when coverage criteria is met. See also banked donor milk.
Nutritional products that are marketed for use of individuals without medical conditions are not a covered benefit.
Nutritional therapy may be covered in an inpatient or outpatient setting. If covered, the setting where the services are provided will determine costs: outpatient office setting, home setting or inpatient hospital setting. Therapy administered by a registered dietician or nutritionist must be supervised by a physician.
To expedite the review process, providers may attach a Letter of Attestation in lieu of clinical documentation to the authorization request.
