Oral Nutrition Mandate — Oral Nutrition Products (non-prescription formulas and low-protein foods)
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Defines coverage for non-prescription oral nutritional formulas, special medical formulas, and low-protein foods for home use for commercially insured members when prescribed by a physician for specified malabsorption or inborn errors of metabolism; describes reimbursement and prior authorization processes.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Coverage Criteria
Covered when ALL of the following are met
See applicability to Commercial Products
Physician prescription or written order required per RIGL 27-20-56
List of qualifying conditions per RIGL 27-20-56 and policy details
Specific infant criteria described in policy and definitions
This policy excludes coverage for donor breast milk therapy; donor breast milk is expressly not a covered service under Blue Cross & Blue Shield of Rhode Island plans. The policy also does not address enteral nutrition delivered as the sole source of nutrition via feeding tube—such tube feeding is governed by the Enteral/Parenteral Nutrition Therapy policy referenced in Related Policies. The scope of this policy is limited to non-prescription oral nutritional formulas, special medical formulas, and low-protein foods for home use when prescribed by a physician for the qualifying clinical indications listed in this document.
When the stated medical criteria are not met, oral nutritional formulas, special medical formulas, and low-protein food products are non-covered and constitute a contractual exclusion for all Commercial products. Providers should note that prior authorization is recommended for Commercial products, but coverage remains contingent on meeting the physician order and clinical indication requirements described in this policy.
Coding
Provider Actions & Requirements
Prior Authorization via web-based 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 as listed under Coordination of Care.
- Prior authorization recommended for Commercial Products
- Authorization obtained via BCBSRI online authorization tool for participating providers
- Non-participating providers: use Preauthorization Form for Oral Nutrition
Coverage contingent on meeting listed criteria
Coverage for low protein food products, oral nutritional formulas, and special medical formulas is contingent on meeting the policy's listed clinical criteria. These products are covered for Commercial Products only when ordered by a physician and the member meets the specified diagnosis criteria (for example: PKU, tyrosinemia, Crohn's disease, ulcerative colitis, gastroesophageal reflux, chronic intestinal pseudo obstruction, inherited diseases of amino acids and organic acids, or specified infant milk/soy protein allergy with failure to thrive and blood in stools). If the criteria are not met, these products are non-covered and are a contractual exclusion.
- Coverage applies to Commercial Products only
- Covered when ordered by a physician and member meets listed diagnoses/criteria
- Non-covered and contractual exclusion if criteria are not met
Member reimbursement documentation
Members seeking reimbursement after preauthorization approval must submit itemized receipt(s) that highlight or circle the special foods purchased, along with the completed Oral Enteral Food Products Reimbursement Form (or reimbursement form listing the special foods purchased). Documentation must be submitted within one year from the date of purchase to the Claims Department at Blue Cross & Blue Shield of Rhode Island.
- Submit itemized receipts highlighting/circling purchased special foods
- Include completed Oral Enteral Food Products Reimbursement Form (see Coordination of Care)
- Submit within one year from purchase date
- Mail to: Attention: Claims Department, Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence, RI 02903-2699
Background
Rhode Island General Law (RIGL) §27-20-56 mandates coverage for nonprescription enteral nutrition products for home use when a physician orders them and they are medically necessary to treat malabsorption caused by conditions such as Crohn’s disease, ulcerative colitis, gastroesophageal reflux, chronic intestinal pseudo-obstruction, and inherited diseases of amino acids and organic acids. This policy implements that statute for Commercial products only, defines the qualifying diagnoses, and describes the authorization and claims submission processes required for reimbursement.
Definitions
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