MNT referral form template
By Javier Alvarez · Updated · 3 min read
| Who can refer (Medicare) | A physician (MD or DO) |
|---|---|
| Covered conditions | Diabetes, renal disease (not on dialysis), 36 months post kidney transplant |
| CKD range | GFR 15 to 59 mL/min/1.73m² |
| Hours | 3 the first calendar year, 2 each year after |
| Extra hours | New referral for a change in diagnosis, condition or treatment (G0270/G0271) |
| On the claim | Referring provider name and NPI (CMS-1500 box 17, 17b) |
Medicare MNT claims fail on the referral more than on anything clinical: no referral on file, a referral signed by the wrong kind of provider, last year's referral used for this year's visits, or a diagnosis Medicare doesn't cover. This form puts everything Medicare's MNT rules ask for on one page, with your practice's return details printed on it, so the physician's office can check boxes, sign and fax it back.
How to use the form
- Add your practice details: your name and credentials, practice, NPI, phone, fax and a referral email. They print in the header and in the "please return to" line.
- Choose the sections. Keep the commercial-plan diagnoses if you also see non-Medicare patients, the diet order block, and the list of labs to attach.
- Print or save as PDF and send it to the referring office. Patient fields stay blank for the physician's office to complete.
Nothing you type is stored or sent. Click Fill with example to see it with invented details.
What Medicare requires on the referral
Medicare's MNT benefit is set by 42 CFR 410.130 to 410.134 and NCD 180.1. The parts a referral has to satisfy:
- A physician refers. The regulation defines physician as a doctor of medicine or osteopathy. Since 2022 it no longer has to be the "treating" physician, but it still has to be an MD or DO.
- A qualifying diagnosis, documented by the referring physician in the patient's medical record: diabetes, or renal disease.
- Renal disease means chronic kidney disease with a GFR of 15 to 59 mL/min/1.73m², end-stage renal disease when dialysis is not received, or the 36 months after a kidney transplant. Patients on maintenance dialysis get nutrition care through the dialysis facility, not this benefit. That's why the form asks for the most recent eGFR and its date.
- Hours. 3 hours in the first calendar year, 2 hours each year after. Unused hours don't carry over.
- A new referral every calendar year for follow-up hours, as Noridian and other contractors state.
- Extra hours in the same year need a second referral for a change in diagnosis, medical condition or treatment regimen, billed as G0270 or G0271.
The diabetes codes on the form leave the digits after E10., E11. and O24.4 blank on purpose: the physician codes to the documented specificity.
Commercial payers that want a referral
Commercial plans set their own rules. HMOs and some point-of-service plans require a referral from the primary care provider before any specialist visit, dietitians included; some PPOs require one only for specific diagnoses; many require none. The optional "other diagnoses" section (prediabetes R73.03, hyperlipidemia E78.x, hypertension I10, overweight or obesity E66.x with the BMI code) lets the same form serve those patients. Our guide to physician referrals for dietitians covers how to build a referral pipeline, and the benefits verification script tells you what to ask the plan.
The referring provider on the claim
For Medicare MNT, the referring physician goes on the claim. On the CMS-1500, box 17 carries the name with qualifier DN (referring provider) and box 17b the NPI, per the NUCC instructions. An electronic claim carries the same data in the referring provider loop. A missing or mismatched referring NPI is a common front-end rejection, so copy it from the signed referral, not from memory.
Renewal: a new calendar year, and G0270
Put a reminder on every Medicare patient for January: their follow-up hours for the new year need a new referral before the first visit. When the diagnosis, condition or treatment changes mid-year and the patient needs more than the year's hours, request a second referral that states the change, then bill the extra time as G0270 (individual, 15-minute units) or G0271 (group, 30-minute units). The Medicare MNT billing guide has the full sequence.