Ohio Admin. Code 5160-10-26 - DMEPOS: nutrition products
(A)
Coverage.
(1)
Enteral and
parenteral nutrition.
(a)
The default certificate of medical necessity (CMN) form
is the ODM 01907, "Certificate of Medical Necessity: Enteral and Parenteral
Nutrition" (rev. 7/2018). The CMN must include the following information:
(i)
Attestation to
one of the following statements:
(a)
The individual is able to ingest food but cannot derive
sufficient energy and nutrients from ordinary food, even if the food is
prepared in a liquefied, puréed, or blended form;
(b)
The individual is
unable to ingest food safely but can digest it; or
(c)
The individual is
unable to digest food in the alimentary canal and must obtain nutrition
parenterally.
(ii)
For an individual who has difficulty in maintaining
weight, a current weight history; and
(iii)
For an
individual who requires a daily intake of more than two thousand calories, an
explanation of the need.
(b)
A new
prescription is required for a change in the type or increase in the quantity
of an item.
(c)
Substitutions are permitted, so long as the substituted
product is correctly formulated to meet the needs of the individual and the
prescriber is notified before the supplier dispenses the product.
(d)
Payment will not be made for quantities that exceed one
month's supply.
(e)
Suppliers must not dispense supplies more than one week
before the scheduled dispensing date.
(f)
Payment includes
dispensing and either shipping or delivery.
(2)
Provision of
donor human milk.
(a)
Payment can be made only to a medicaid-enrolled
provider that is a member in good standing of the human milk banking
association of North America.
(b)
The provider must
keep on file the following documents:
(i)
An explanation by
a prescriber of the medical necessity of human milk for the
recipient;
(ii)
An attestation that the prescriber has given the
recipient's parent or guardian information about human milk (e.g., nutrients,
growth factors, shelf life, the effects of pasteurization, the possibility of
disease transmission) and the donation process (e.g., donor screening,
pasteurization, storage, transport), which may be in the form of educational
material obtained from the provider; and
(iii)
A consent form,
signed and dated by the recipient's parent or guardian, indicating that the
parent or guardian has been made aware of the benefits and risks of using
banked donor human milk.
(c)
No separate
payment is made to a provider for supplying donor human milk
(d)
Payment includes
processing and either shipping or delivery; no payment is made for the milk
itself.
(B)
Constraints and
limitations. Separate payment will not be made for the following items as
medical supplies:
(1)
Ordinary prepared food;
(2)
Commercial
products that serve as ordinary food (e.g., shakes, smoothies, energy bars,
vitamin or mineral supplements, baby food);
(3)
Food products to
be eaten as part of a diet related to diabetes, obesity, gastric bypass, or
bariatric surgery;
(4)
Food products for which a provider receives medicaid
per diem payment; and
(5)
Standard infant formula (not used to treat errors of
metabolism) for which payment may be made through a program other than
medicaid.
Replaces: 5160-10-26
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 01/01/2006, 08/18/2008, 01/01/2010, 08/02/2011
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