DATE:		______________________________

TO:		______________________________
                                                          (Insurance Company)
FROM:	______________________________

SUBJECT:	______________________________

I am requesting insurance coverage and reimbursement for my patient, ___________________________________, for whom I have prescribed the use of Neocate® Junior (manufactured by Nutricia North America).

I feel that Neocate Junior is a medical necessity and will provide the proper dietary management for this patient, who has been diagnosed with __________________________________.  Without the use of Neocate Junior, my patient may experience complications of the condition, which may result in hospitalization and/or costly parenteral nutrition.

Neocate Junior is an amino acid based nutritionally complete elemental formula. It is specifically designed for children over one year of age with gastrointestinal impairment due to milk protein sensitivity or other medical conditions affecting the gastrointestinal tract. Its unique formulation (100% free amino acids, milk free, gluten free, and soy protein free) provides complete nutrition and can be the sole source of nutrition. Neocate Junior has an elemental composition, which requires minimal digestion, thus ideally suited for patients with compromised gastrointestinal function.

The FDA classifies Neocate Junior as a “medical food” which must be used under medical supervision and is not sold over the counter or at the retail level.  Therefore, Neocate Junior is only available through a pharmacy or through Nutricia North America directly (with medical consent).  For additional reimbursement codes and information, please see the reverse side.

Your approval of this request for insurance coverage and reimbursement of the Neocate Junior would make a significant impact on this patient’s health.

Sincerely,

NEOCATE AND REIMBURSEMENT

Third-party payers such as Medicaid and HMOs will reimburse for the cost of Neocate Junior.  To process claims for Neocate Junior, payers require a reimbursement code to identify the nutritional product/category.  Some states have enacted legislation, which require that reimbursement be provided based on the patient’s diagnosis.

Claims are usually processed in one of two ways.  A code is used to identify Neocate Junior through the HCFA Healthcare Procedure Coding System (HCPCS), or through the National Drug Code (NDC) system.  Most states will use one of these systems to classify Neocate Junior for reimbursement purposes.  Individual insurance plans will also choose one of these systems to reimburse patients for nutritional products.

CODING SYSTEMS:

MEDICARE (HCPCS)

Neocate Junior is classified under Code # B4161.

NATIONAL DRUG CODE (NDC)

Neocate Junior is not a drug but is classified by the FDA as a “medical food”, which requires usage under strict medical supervision. The NDC code for the Neocate Junior is:
	49735-0117-90		Neocate Junior, unflavored
	49735-0121-24		Neocate Junior, tropical
	49735-0126-90		Neocate Junior, chocolate