Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Durable Medical Equipment Bulletin 14 April 2008 TO: Durable Medical Equipment Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Clarification of Coverage of Formulas (Enteral-Nutrition Products) Background This bulletin clarifies coverage of certain enteral-nutrition products for MassHealth members who may also be eligible for enteral-nutrition products provided by the Department of Public Health’s (DPH) Women, Infants and Children (WIC) nutrition program. WIC may refer to enteral- nutrition products as “special,” “prescription,” or “regular” formulas. Members who may qualify for the WIC program include pregnant, postpartum, and breastfeeding women, infants, and children under the age of five. Enteral Nutrition Covered by WIC The table below reflects the enteral-nutrition products that WIC covers. For these products, MassHealth is payer of last resort. Providers may contact the DPH WIC help line at 1-800-WIC-1007 for further information on limits or other coverage information. Formula Type Available* Good Start Supreme DHA/ARA P, C, R Good Start Supreme Soy DHA/ARA P, C, R Good Start Supreme P Enfamil Lipil with Iron P, C, R Enfamil Lipil Low Iron P, R ProSobee Lipil P, C, R *P= Powder C= Concentrate R= Ready to use (continued on next page) Enteral Nutrition not Covered by WIC MassHealth(including its contracted Managed Care Organizations ((MCOs)) has primary responsibility for payment of enteral-nutrition products that are not on the above list of enteral-nutrition products covered by WIC for MassHealth members who are eligible to receive enteral nutrition through the WIC program. General PA Requirements for Enteral Nutrition MassHealth covers enteral-nutrition products that are medically necessary in accordance with 130 CMR 450.204. All enteral-nutrition products are provided as a DME benefit and require prior authorization (PA). MassHealth DME providers and pharmacy providers with a DME specialty must submit prior-authorization requests in accordance with Appendix A of the All Provider Manual. In addition, a signed prescription and written documentation of medical necessity from the member’s physician or nurse practitioner must accompany the prior-authorization request in accordance with the DME regulations at 130 CMR 409.000. NOTE: PA requests for enteral-nutrition products for MCO members must be processed by the respective MCO. PA Requirements for Enteral-Nutrition Products not Covered by WIC If the PA request is for an enteral-nutrition product that is not on the above list of enteral-nutrition products covered by WIC, and the member may qualify for WIC as described in the first paragraph above, MassHealth will process the PA request with the above medical documentation, and no proof of WIC eligibility is needed. PA Requirements for Enteral-Nutrition Products Covered by WIC If the PA request is for an enteral-nutrition product that is on the above list of enteral-nutrition products covered by WIC, and the member may qualify for WIC as described in the first paragraph above, MassHealth requires proof of the member’s WIC eligibility. Providers must obtain from the member WIC documentation that the member is either WIC eligible or WIC ineligible, and submit this documentation along with the PA request and the required medical documentation. If MassHealth does not receive this documentation with the PA request for enteral nutrition, MassHealth may defer or deny the PA request. (continued on next page) PA Requirements (cont.) Upon receipt of a completed PA request for an enteral-nutrition product that is on the above list of enteral-nutrition products covered by WIC, MassHealth will determine that the member is: 1. WIC eligible and will receive enteral nutrition sufficient to meet the member’s medical need through WIC (note that in the absence of a demonstrated need, MassHealth will deny the PA); 2. WIC ineligible and enteral nutrition will not be provided by WIC; or 3. WIC eligible, and the PA request is for enteral nutrition above the amount that WIC will provide the member. In such cases, the PA request must include the WIC documentation as well as medical documentation from the member’s physician or nurse practitioner to support the request for enteral nutrition beyond the amount provided by WIC. MassHealth will then process the PA request and approve, modify, or deny the request and notify the member and the provider of its decision. Service Codes and Descriptions Providers should consult Subchapter 6 of the Durable Medical Equipment Manual for information on service codes and descriptions for enteral-nutrition products. 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. PA Guidelines 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. MassHealth has also published on its Web site the Medical Necessity Review Form for Enteral Nutrition Products, which providers can download and use when submitting requests for PA. (continued on next page) Questions If you have any questions about the information in this bulletin, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. For MassHealth MCO members, providers must contact the appropriate MCO Customer Service Center listed below. • Boston Medical Center Health Plan:1-888-566-0008 or 1-800-900-1451 • Fallon Community Health Plan: 1-866-275-3247 • Network Health: 1-888-257-1985 • Neighborhood Health Plan: 1-800-462-5449