Prescriber Statement Of Medical Necessity Nutritional Supplement Pre-Authorization Form Page 2
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2M
M
P
P
ARYLAND
EDICAID
HARMACY
ROGRAM
PH 18009323918
FAX 18664409345
PRESCRIBER STATEMENT OF MEDICAL NECESSITY
NUTRITIONAL SUPPLEMENT PRE-AUTHORIZATION FORM
Incomplete forms will be returned for reprocessing
1. Patient’s Name:______________________________________________
Phone: _______________________________
Patient’s Address:_______________________________________________________________________________________
Patient’s Medicaid ID #:_______________________________________
DOB:_________________________________
Patient Location:
Residence
Nursing Home
Hospital
Date Last Doctor’s Visit:__________________
Body Weight:
_______kg or _______lb Height: _____ft. ____in. Date Measured:________________________
2. Justification for nutritional supplement need
a) Diagnosis __________________________________________
Date of onset __________________________
b) Does recipient have an inborn error of metabolism?
Yes
No
?
Yes
No
c) Is patient currently tube-fed
If partially tube-fed, only amount that is actually tube-fed will be approved. Please check % of tube-feeding:
100%
75%
50%
25%
<25%
Anticipated duration of tube feeding
______(# days)
_____(# months)
_____indefinitely
Place G-tube inserted:______________________________________
Date G-tube inserted___________________
d) 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 comprehensive metabolic panel including prealbumin and serum magnesium & phosphorus levels
a BMI-for-age chart besides the standard or clinical growth chart. All plotted values on the chart must be legible
a recent medical history documenting nutritional status and any weight loss over the prior 6 months
with height/weight measurements and corresponding dates.
e) Calories prescribed initially verified by _____________________________ Ph.:_______________ 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/ml/pkt, etc.)
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 minus b must equal c. Explain reason for exceeding the average caloric daily requirement:
__________________________________________________________________________________________________
d. # calories per each unit dispensed: __________________ calories per _________________ (specify unit below)
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/month)
f. _________ cans/day
Specify: _________ ml/can
#___________gm/day
_____________#packet/day
g. Calories prescribed: ______________cal/Kg/day Body Weight:____________Kg Date measured:_________________
NPI # ___________________________
4. Prescriber’s Signature:_______________________________________________
Prescriber’s Name:__________________________________________________
Degree: _________________________
Address: ________________________________________________________________________________________________
Phone: __________________________
Fax: ________________________
Date:___________________________
5. Name of Pharmacy verifying calorie conversion into proper units billed ________________________________________________
Pharmacy Address_________________________________ Ph.________________ Fax_______________ Date_____________
FOR INTERNAL USE ONLY
APPROVED (enter dates) from:__________ to _________
REJECTED Date:________
Initials: ___________
DHMH 3495 (Rev. 03/2011) - Form may be duplicated
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