Oral Nutrition Mandate
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Coverage criteria and prior authorization/process rules for non-prescription oral nutritional formulas, low-protein food products, and special medical formulas for commercial members when prescribed for specified malabsorption or inborn errors of metabolism.
No material clinical or coverage changes in this revision.
Coverage Criteria
Covered Indications (Commercial Products)
Covered when ALL of the following are met for Commercial products:
Overall
- Covered indications: One of the following diagnoses is present: Crohn's disease; Ulcerative colitis; Gastroesophageal reflux; Chronic intestinal pseudo-obstruction; Inherited diseases of amino acids and organic acids (including but not limited to phenylketonuria [PKU], tyrosinemia, homocystinuria, maple syrup urine disease, propionic aciduria, methylmalonic aciduria).
Coverage for inherited amino acid/organic acid disorders includes low-protein modified food products and extends to all ages.
- Infant milk/soy allergy exception: For infants age 0-12 months with milk or soy protein allergy, coverage of oral nutritional or special medical formulas is allowed when failure to thrive and blood in the stools are present.age 0-12 months
Applies to physician-ordered formulas for home use; these infant formulas are typically prescription products obtained from a pharmacy.
Low protein food products, oral nutritional formulas, and special medical formulas are non‑covered and a contractual exclusion for all Commercial products when the specified coverage criteria in this policy are not met.
Donor breast milk therapy is not a covered service under Blue Cross & Blue Shield of Rhode Island plans.
Services that do not meet the criteria set forth in this policy are not covered and are considered a contractual exclusion under Commercial products.
Coding
Provider Actions & Billing
Obtain prior authorization via online tool
Prior authorization is recommended for Commercial products and must be obtained via the payer's online authorization tool for participating providers. Non‑participating providers should use the Preauthorization Form for Oral Nutrition referenced in the policy.
- Use the online authorization tool if you are a participating provider.
- Non‑participating providers: complete the Preauthorization Form for Oral Nutrition referenced under Coordination of Care.
No step therapy requirements specified
There are no step therapy requirements specified in this policy for Commercial products; providers do not need to complete any step‑therapy checks before requesting authorization under this policy.
Member reimbursement: submit receipts and reimbursement form within one year
After preauthorization approval, members may be reimbursed for eligible food products only if the member submits itemized receipts that highlight the special foods and the completed reimbursement form within one year of purchase to the BCBSRI Claims Department.
- Send itemized receipts (special foods highlighted or circled).
- Include the Oral Enteral Food Products Reimbursement Form.
- Submit both within one year from the date of purchase to: Attention: Claims Department, Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI 02903-2699.
Non‑coverage risk for low‑protein foods and oral/special formulas when criteria not met
Claims for low protein food products, oral nutritional formulas, and special medical formulas are non‑covered and are a contractual exclusion when the policy criteria are not met; submit authorizations/documentation only when the coverage criteria in the policy are satisfied.
- Coverage requires the physician order and that the member meet one of the specified diagnoses or the infant exception (0–12 months with failure to thrive and blood in stools).
- If criteria are not met, the items are non‑covered and may be denied as a contract exclusion.
Definitions
Background
Rhode Island law requires coverage of nonprescription enteral formulas for home use when a physician provides a written order and the product is medically necessary to treat malabsorption caused by specified gastrointestinal diseases or inherited amino acid/organic acid disorders. Coverage for inherited amino acid/organic acid disorders includes low‑protein modified food products and applies regardless of age.
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