Prescriber Statement Of Medical Necessity Nutritional Supplement Pre-Authorization Form

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ARYLAND

EDICAID

HARMACY

ROGRAM

18009323918

18664409345

PRESCRIBER STATEMENT OF MEDICAL NECESSITY

NUTRITIONAL SUPPLEMENT PRE-AUTHORIZATION FORM

BILLING INSTRUCTIONS FOR PHARMACY PROVIDER

NUTRITIONAL SUPPLEMENT PROGRAM

Upon notification of approval of payment for the nutritional supplement by the Program, pharmacy providers are to submit

claims on-line as follows:

1. Bill the actual NDC of the nutritional product dispensed.

a. Bill the exact units as quantity dispensed. Units must be accurate, expressed in”ml” 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 exact unit package size.

b. Exceptions to the use of the ready-to-use form: This dosage 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.

c. Maximum 34 days supply per Rx. Max # of refills per Rx is 11. Although nutritional supplements are considered

over-the-counter products, the Program still requires a valid prescription for the products to be dispensed. Such

prescriptions should be retained and ready for audit as would a legend prescription.

2. Claim will initially deny with any of the following NCPDP exception codes: “70 = NDC Not Covered”, “75= PA required”,

“76 = Max Quantity Exceeded”, “78 = Cost Exceeds Max”, or “88 = Overuse/Early Refill”, etc. Providers must call the

Program at 1-800-492-5231, Option 3 for pre-authorization. Pre-authorization may be issued for an extended period

once the nutritional supplement need has been established via review of Form 3495 (Prescriber Statement of Medical

Necessity-Nutritional Supplement Pre-Authorization Form).

3. For refill requests, fax Form 3495 C- Nutritional Supplement Service Pre-Authorization (PA) Request to the Program

at 410-333-5398. After the service PA has been entered on-line by the Program, provider will be notified by facsimile

to resubmit claim. If the claim should deny for additional exception codes, provider should fax another 3495 C service

PA request to the Program. In case of urgency, provider may call the Program for further assistance.

4. Nutritional supplement orders are ideally and initially verified or recommended by a licensed nutritionistdietician. For

continuation of nutritional therapy, a new Nutritional Supplement Pre-Auth Form (3495) must be completed and

resubmitted to the Program when it expires. Any change in the prescription requires completion of a new 3495.

5. For requests for payment of oral nutritional supplements for REM recipients who are not tube-fed, nor have a metabolic

disorder, providers must submit to the Program: 1) a comprehensive metabolic panel with Mg and Phosphorus levels;

2) dated measurements of weight, height, with BMI; 3) percentile placement on the BMI-for-age chart and growth chart if

under 18; and 4) serum pre-albumin level.

6. Continued use of nutritional supplements for REM recipients will be reviewed by the Program every 6 months to a year

depending on the case. For recipients without evidence of medical need or proper documentation, a one-time 30-day

emergency supply of the requested nutritional supplement will be pre-authorized until the proper documentation is

received by the Program for determination of nutritional need.

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This form may be faxed to 8664409345