Updates to Parenteral and Enteral Nutrition Therapy Billing

According to the TRICARE Policy Manual, Chapter 8, section 7.1, B, medically necessary nutritional products which are provided under paragraph III.A and which are on the Enteral Nutrition Product Classification List are eligible for TRICARE cost-sharing. The list is maintained by the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) and is currently available online at: http://www2.palmettogba.com/classifications/enteral%20nutrition.pdf

You will be reimbursed for these nutritional products based on the Centers for Medicare and Medicaid Services (CMS) Parenteral and Enteral Nutrition Items and Services (PEN) Fee Schedule, less any contractual discounts. For those services not priced on the PEN fee schedule, reimbursement for nutritional products will be priced at the average wholesale price (AWP), less any contractual discounts.

You should bill for parenteral and enteral nutrition therapy services using the appropriate HCPCS "B" codes along with the National Drug Code (NDC). You also should bill the number of units provided based on the "B" code description. Claims for services billed with J3490 will be returned to you for a better code.

All enteral therapy services require prior authorization by TriWest. Please see the Prior Authorization List (PAL) in the Provider Connection section of www.triwest.com.