Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Physician Bulletin 87 August 2008 TO: Physicians Participating in MassHealth (Including Acute Inpatient Hospitals, Acute Outpatient Hospitals, and Independent Diagnostic Testing Facilities Billing for the Professional Component of Services) 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 (also referred to as regular and special formulas) provided by the Department of Public Health’s (DPH’s) Women, Infants and Children (WIC) Nutrition Program. Members who may qualify for the WIC program include pregnant, postpartum, and breastfeeding women; infants; and children under the age of five. Coverage by WIC The WIC program has primary responsibility for the provision of regular formulas to WIC-eligible MassHealth members. The regular formulas covered by WIC are listed below. Formula Type Available* Maximum Amount/Month Provided by WIC Good Start Supreme DHA/ARA P, C, R P 9 (12.0 oz.), C 31 (13.0 oz.), R 25 (32.0 oz.) Good Start Supreme Soy DHA/ARA P, C, R P 9 (12.0 oz.), C 31 (13.0 oz.), R 25 (32.0 oz.) Good Start Supreme P P 10 (12.0 oz.) **Enfamil Lipil with Iron P, C, R P 9 (12.0 oz.), C 31 (13.0 oz.), R 25 (32.0 oz.) **Enfamil Lipil Low Iron P, R P 9 (12.0 oz.), R 25 (1 qt.) **ProSobee Lipil P, C, R P 9 (12.9 oz.), C 31 (13.0 oz.), R 100 (8.0 oz.) **Contact WIC Regarding Availability *P= Powder C= Concentrate R= Ready to use MassHealth Physician Bulletin 87 August 2008 Page 2 Coverage by MassHealth MassHealth (including its contracted Managed Care Organizations (MCOs)) will provide coverage of enteral products only under the following circumstances and with prior authorization (PA): o the member is not eligible for WIC; o the member requires special or prescription formula not on the WIC list; or o the member does not receive adequate amounts of regular formula from WIC to meet the member’s medical needs. Prior-Authorization The supplier of enteral nutrition products—that is, a MassHealth oxygen Documentation and respiratory therapy equipment provider, durable medical equipment (DME) provider, or pharmacy provider with a DME specialty—has primary responsibility for submitting the PA request to MassHealth for enteral- nutrition products. However, the PA request must be supported by the physician’s or nurse practitioner’s prescription and documentation of medical necessity. MassHealth has published Guidelines for Medical Necessity Determination for Enteral Nutrition Products, which can be viewed on MassHealth’s Web site at: http://www.mass.gov/Eeohhs2/docs/masshealth/guidelines/mg- enteralnutrition.pdf. MassHealth has also published the Medical Necessity Review Form for Enteral Nutrition Products, which can be viewed at: http://www.mass.gov/Eeohhs2/docs/masshealth/guidelines/mnr_enteraln utrition.pdf Providers may download and use this form when submitting requests for prior authorization or use a letter on the physician’s or nurse practitioner’s letterhead describing medical necessity along with a prescription for the formula. For a MassHealth MCO member, the provider must contact the Customer Service Center where the member is enrolled for information on his or her PA process. (continued on next page) MassHealth Physician Bulletin 87 August 2008 Page 3 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. o Boston Medical Center HealthNet Plan:1-888-566-0008 or 1-800-900-1451 o Fallon Community Health Plan: 1-866-275-3247 o Network Health: 1-888-257-1985 o Neighborhood Health Plan: 1-800-462-5449.