ࡱ> KMJ 9.bjbj ]Djjw%l$    " $)2R R R R R R R R T!V!V!V!'}!M%)* -)iR R R R R )R R )R BR R T!R T! r (!R F "WR  (!,)0) z-b-(!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. Patients Name________________________________________________Phone # __________________ Patients Address_______________________________________________________________________ Patients Medicaid ID # ______________________________________Date of Birth:________________ Patient location: ___Residence; ___Nursing Home; ___Hospital- Date of last doctors 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: l gram; l ml (concentrate); l ml (ready-to-use); l packet; l 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. Prescribers Signature:_______________________________Medicaid ID# ______________________ Prescriber s Name:____________________________Title: l MD- l CNP- l Certified Nutritionist Address: ____________________________________________________________________________ Phone# (____) ____________ Fax: (_____) ________-___________ Date: _____/________/______ PHARMACY Pharmacists or professional staff must verify calories conversion into proper units billed. Pharmacys Name________________________________________Phone# (_______)________-________ Pharmacys 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: Bill the actual NDC of the nutritional product dispensed. Bill the exact units as quantity dispensed. Units must be exact, expressed incc 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. 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. 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. 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. 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. l 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. l 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 c:\MSWord\Nutritionals3495Apr 07 O DHuXl , jk5679 vKq [^ltu.5K78_$<4 "aJ 5\aJCJ>*CJ5\>*CJ 5CJ\CJ 5>*CJ\CJ 5CJ\R*OHkCD ^ .  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L ^ `L.  ^ `.^`.WLW^W`L.''^'`.^`.L^`L.h^`CJOJQJo(qh ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(GG^G`o(.^`. L ^ `L.  ^ `.^`.WLW^W`L.''^'`.^`.L^`L.q(41pA,^q @ 0^`0OJQJo(n                 pD>        i s$y%@HP1012Ne00:winspoolhp LaserJet 1012HP1012<4XSDDMhp LaserJet 1012ZddHP1012<4XSDDMhp LaserJet 1012Zddd EE>> >!w%@@@@(@@@0@@&@(@T@UnknownGz Times New Roman5Symbol3& z Arial;Wingdings?5 z Courier New"A hf&3[kAY xx2d% 2Q )PRESCRIBER STATEMENT OF MEDICAL NECESSITYNGUYENTShookMOh+'0 (4 P \ h t*PRESCRIBER STATEMENT OF MEDICAL NECESSITYrdRESNGUYENTGUYGUYNormalShookM18oMicrosoft Word 9.0T@y0@Ӂx@F vq@ҫWk՜.+,0 hp  DHMHBA% *PRESCRIBER STATEMENT OF MEDICAL NECESSITY Title  !"$%&'()*+,-./0123456789;<=>?@ACDEFGHILRoot Entry F4WN1Table#-WordDocument]DSummaryInformation(:DocumentSummaryInformation8BCompObjjObjectPool4W4W  FMicrosoft Word Document MSWordDocWord.Document.89q