• Editor: Vic Vangel • Contributors: Chris Burke, Gary Gilmore, Paul Jeffrey, James Monahan, Nancy Schiff, Chuck Young • 
www.mass.gov/masshealth/pharmacy 
Number 41 
June 6, 2008 
• Editor: Vic Vangel • Contributors: Chris Burke, Gary Gilmore, Paul Jeffrey, James Monahan, Nancy Schiff, Chuck Young • 
www.mass.gov/masshealth/pharmacy 
Number 41 
June 6, 2008 
DME Claims for Enteral-Nutrition 
Products--Processing Update 
MassHealth recently issued Pharmacy Facts #40, 
which gave general information about prior 
authorization (PA) and claim submission for durable 
medical equipment and medical supplies (DME). This 
edition of Pharmacy Facts will expand on Pharmacy 
cases, no proof of WIC eligibility is necessary. In 
order to obtain enteral-nutrition products that are 
available through WIC, providers must obtain WIC 
documentation from the member that states that the 
member is either WIC eligible or WIC ineligible, and 
submit it to MassHealth along with the PA request and 
other supporting documentation. 
Facts #40 and give an update on the processing of The WIC program covers the following products as 
claims for enteral-nutrition formulas. Information first payer for MassHealth members 
concerning this topic was also released in MassHealth Good Start Supreme 
DME Bulletin 14: Clarification of Coverage of Formulas Good Start Supreme DHA/ARA, 
(Enteral-Nutrition Products). This bulletin can be found Good Start Supreme Soy DHA/ARA 
on the MassHealth Web site, Enfamil Lipil with Iron, 
www.mass.gov/masshealth. Go to MassHealth Enfamil Lipil Low Iron 
Regulations and Other Publications. Click on the link ProSobee Lipil 
for Provider Library and then for Provider Bulletins. 
MassHealth covers medically necessary enteral-
nutrition products in accordance with 130 CMR 
450.204. These products are covered as a DME 
benefit and require prior authorization (PA). Pharmacy 
providers who have been approved by MassHealth to 
provide DME (referred to here as DME providers), 
must obtain a signed prescription and written 
documentation of medical necessity from the 
member’s physician or nurse practitioner, then submit 
the documentation along with the prior authorization 
request in accordance with DME regulations at 130 
CMR 409.000. A DME provider must submit prior 
authorization requests to MassHealth when 
presented with a valid prescription and written 
documentation of medical necessity. 
DME providers should consult Subchapter 6 of the 
Durable Medical Equipment Manual for information on 
service codes and descriptions for enteral-nutrition 
products. DME providers may also find service codes 
and descriptions in the DME and Oxygen Payment 
and Coverage Guidelines Tool available on the 
MassHealth Web site at www.mass.gov/masshealth. 
Go to MassHealth Regulations and Other Publications, 
then Provider Library. 
For MassHealth members, MassHealth has primary 
responsibility for enteral-nutrition products not covered 
by the Department of Public Health (DPH) Women, 
Infants and Children (WIC) nutrition program. In such 
Upon receipt of a completed PA request for an enteral-
nutrition product that is on the above list, MassHealth 
will determine that the member is: 
1. WIC eligible and will receive enteral-nutrition 
products sufficient to meet the member’s medical 
need through WIC (in the absence of a 
demonstrated need, MassHealth will deny the PA); 
2. WIC ineligible (enteral-nutrition products will not 
be provided by WIC); or 
3. WIC eligible, and the PA request is for enteral- 
nutrition products in excess of the amount that 
WIC will provide the member. In such cases, the 
PA request must include WIC documentation and 
medical documentation from the member’s 
physician or nurse practitioner to support the 
request for enteral nutrition beyond the amount 
provided by WIC. 
MassHealth has published Guidelines for Medical 
Necessity Determination for Enteral Nutrition Products, 
which can be viewed on MassHealth’s Web site at 
www.mass.gov/masshealth. Click on Information for 
Providers, then MassHealth Provider Forms, then 
Forms Used by Multiple Provider Types. The 
MassHealth Web site also includes the Medical 
Necessity Review Form for Enteral Nutrition Products, 
which providers can download and use when 
submitting requests for PA. Providers may contact the 
WIC help line at 1-800-WIC-1007 for coverage 
information. 

Please direct any questions or comments (or to be taken off of this fax distribution) to 
Victor Moquin of ACS at 617-423-9830.