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New Billing Requirements for Formula

Date: 12/05/16

In an effort to better understand the types of orally administered formulas (not by feeding tube) our members, your patients, are utilizing, NH Healthy Families is implementing the following billing requirement effective February 1, 2017.

When billing orally administered formulas not by feeding tube (HCPC codes B4150 through B4162):

  • Include modifier BO
  • Include the name of the formula in box 19 of the HCFA 1500 form for all types of formula.
  • When submitting an electronic claim, include the name of the formula in loop 2300,  NTE – Claim Note segment

As a reminder, the New Hampshire WIC Program provides standard formulas for infants. Standard formula is not covered by NH Healthy Families.

For questions about New Hampshire WIC approved formulas contact the State WIC Office at (603) 271-4546 or WIC@dhhs.state.nh.us.

Please contact provider services with any questions at: 1-866-769-3085.