Prescriber Statement of Medical Necessity

PRESCRIBER STATEMENT OF MEDICAL NECESSITY

NUTRITIONAL SUPPLEMENT PRE-AUTH FORM

Maryland Medicaid - Division of Pharmacy Services

Tel # 410-767-1755 or 1-800-492-5231 Option 3

Fax to: 410-333-5398 (All questions must be answered)

Prescribers: Please complete and sign- Incomplete form will be returned for reprocessing.

1. Patient’s Name______Phone # ______

Patient’s Address______

Patient’s Medicaid ID # ______Date of Birth:______

Patient location: ___Residence; ___Nursing Home; ___Hospital- Date of last doctor’s visit:____/____/___

Body Weight:______Circle kg or lb; Height: ______Date measured:______/______/______

2. Justification for nutritional supplement need:

a/ Diagnosis and dates of onset______

b/ Does recipient have an inborn error of metabolism? Yes____ No____

c/ Is patient currently tube-fed? Yes___No___If partially tube-fed, only amount that is actually tube-fed

will be approved. Please circle % of tube-feeding: 100%; 75%; 50%; 25%; <25%

Anticipated duration of tube feeding ______(# days) _____(# months) _____indefinitely

Place and date when G-tube was inserted:______

For REM recipients not tube-fed and without a metabolic disorder, the following documentation must be

submitted to the Program for a determination of medical necessity for the nutritional supplement:

a/ a comprehensive metabolic panel including prealbumin and serum magnesium&phosphorus levels

b/ a BMI-for-age chart besides the standard or clinical growth chart. All values on the chart must be legible

c/ a recent medical history documenting nutritional status and any weight loss over the prior 6 months

with weight measurements and corresponding dates.

d/ Were calories prescribed initially verified by a licensed nutritionist? __Yes __No- Provide name of

nutritionist consultant:______Phone #:______Fax# ______

The cost saving powder or concentrate form must be used. List valid reasons why these forms are not used:

______

3. Rx: Nutritional Supplement Order- Must prescribe in calories to be converted to billable units (gm/cc/pkt)

Product&Dosage Form:______Package Size:______#cans/Case:_____ Dose&dosage frequency: ______Must specify the following:

A. Total calories required per day: ______% daily requirement:______% B. Total calories derived from regular diet (if patient can eat):______% daily requirement:______%
C. Total calories derived from nutritional supplements: ______% daily requirement:______%
A-B must equal C- Explain reason for exceeding the average calorie daily requirement:______
______

D. # calories per each unit dispensed:______calories per______. Specify unit:

 gram;  ml (concentrate);  ml (ready-to-use);  packet;  Other______

Specify: ______gram/ per can (ie. 423g-480g) or______ml /per can; or______gram/packet

E. # units per day (E =C:D)______x 30 days=______(Total quantity billed on-line)
F. __r______cans/day - Specify:______ml/can ; or #______gm/day –or ______#packet/day
G. Calories prescribed: ______Kcal/Kg/day- Weight:______Kg- Date measured:______

4. Prescriber’s Signature:______Medicaid ID# ______

Prescriber’s Name:______Title:  MD-  CNP-  Certified Nutritionist Address: ______

Phone# (____) ______Fax: (_____) ______-______Date: _____/______/______

PHARMACY –Pharmacists or professional staff must verify calories conversion into proper units billed.

Pharmacy’s Name______Phone# (______)______-______

Pharmacy’s Address______Fax#: (______)______-____________

FOR INTERNAL USE - APPROVED:____ from:______to______REJECTED: ____DATE: ______Initials: _____

DHMH 3495 (Rev. 04/2007) - Form may be duplicated. c:\MSWord\..Nutritionals3495Apr07

Maryland Pharmacy Program- Maryland Medicaid

Nutritional Supplement Program

BILLING INSTRUCTIONS FOR PHARMACY PROVIDER

Upon notification of approval of payment for the nutritional supplement by the Program, pharmacy providers are to submit claims on-line as follows:

q  Bill the actual NDC of the nutritional product dispensed.

q  Bill the exact units as quantity dispensed. Units must be exact, expressed in”cc” for liquids, ready-to-use formulas or liquid concentrates requiring further dilution, “gram” for powders before reconstitution, and “each” for powder in packets. Note: 1 lb canister may contain from 423g to 480 grams of powder; an 8 oz can may =237 or 240ml of ready-to-use liquid depending on the specific product. Do not round-up or estimate quantities. Bill multiples of the unit package size.

q  Exceptions to the use of the ready-to-use form: This form may be dispensed only if there is an unsanitary or unsafe water supply or poor refrigeration if the caregiver has difficulty in correctly diluting concentrated liquid or powdered formula, or if the formula is available only in ready-to-use form. Such information must be documented on the Statement of Medical Necessity form by the prescriber.

q  Maximum allowed on each claim is 34 days supply per Rx. Max # of refills per Rx is 11.

. Although nutritional supplements are considered over-the-counter productds, the Program still requires

a valid prescription for the products to be dispensed. Such prescriptions must be kept on file at the

pharmacy for 6 years.

q  Claim will initially deny with any of the following NCPDP error codes, “70 = NDC Not Covered”, “75= PA required”, “76 – Max Quantity Exceeded”, or “78= Cost Exceeds Max”, or “88-Overuse, Early Refill”, etc. Providers are to call ACS at 800-932-3918 or the State 1-800492-5231 option 3 for an override if the claim should deny. Service overrides may be issued for an extended period which will allow claims to go through without need for prior-authorization during the allowed time frame.

q  Nutritional supplement orders should be initially verified or recommended by a licensed nutritionist. For continuation of nutritional therapy, a new Nutritional Supplement Prior-Auth Form must be completed every 6 months for all recipients unless their clinical conditions warrant a long-term or indefinite prior-authorization from 1 to 2 years. Any change in dosage/dosage frequency requires completion of a new form. Providers will be notified of the status of their nutritional supplement requests within 24 hours of date of request. It is expected that prescribers reassess the nutritional status

of their patients based on this time schedule for possible change in daily calorie requirement as necessitated

by an increase in body weight.

 Requests for prior-authorization for payment of oral nutritional supplements for the REM population who

is not tube-fed, nor have a metabolic disorder will be reviewed on a case-per-case basis with consideration

given to the recipient’s overall nutritional and medical status in addition to his/her percentile placement on

the BMI-for-age chart, her pre-albumin, Mg and Phosphorus levels, etc.

 Continued use of nutritional supplements for non-tube fed REM recipients with no metabolic disorder will

be reviewed every 6 months and a determination of medical necessity will be based on a review of the

mandatory updated BMI-for-age chart, or the standard or clinical growth charts and physician progress

notes. Depending on the particular case, the biochemical tests may not need to be repeated for REM

recipients if they have been performed initially. For patients on existing nutritional supplements without

medical need or proper documentation, a one-time 30 day emergency supply of the nutritional supplement

will be prior-authorized until the proper documentation is received by the State for determination of

nutritional necessity.

.

This form may be faxed to 410-333-5398 or mailed to: Office of Operations, Eligibility & Pharmacy Services (OOEP) - 201 W. Preston St, 4th floor -Baltimore, MD 21201- DHMH 3495

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