Maryland Medical Assistance Pharmacy Program
NOTIFICATION OF APPROVAL/REJECTION OF PAYMENT FOR NUTRITIONAL SUPPLEMENT
To: ______Fax # (______)- (______-______) Date:______
Ref: Recipient: ______, ______MA#: ______
Last Name First Name
___ Notification of Approval of Payment for Nutritional Supplement
Above Recipient has been approved for payment of his/her nutritional supplement. The Prescriber must fax
a prescription for the nutritional supplement along with a copy of the Nutritional Supplement Prior-Auth Form to
the pharmacy. The Pharmacist is first to bill on-line for the approved product, let the claim reject, then fax to
the Program a completed Provider Nutritional Supplement Service P/A Request (Form 3495C) along with a copy
of the Nutritional Prior-Auth Form (Form 3495). Prior-authorizations of payment for nutritional supplements
may be issued fro a period ranging from 6 months to 2 years, depending on the recipient’s diagnoses, clinical
status and nutritional supplement need. Once the service overrides are issued by the State for the approved
time period, claims for the nutritional product will adjudicate on-line without requiring further service PAs
during the approved period. However, Form 3495 C must be completed and faxed to the State whenever
the claim denies and requires additional overrides for any DUR error codes. A change in nutritional product or
dosage prescribed requires completion of new 3495 and 3495C forms.
___ Notification of Rejection of Payment for Nutritional Supplement
__MA Recipients Not in the Rare and Expensive Management (REM) Program , not tube-fed, and without an
error of metabolism: Above recipient’s request of payment for nutritional supplements has not been approved
because recipient did not meet the Program’s criteria for nutritional coverage under the Medical Assistance
Program. No exception to this regulation.
__Rare and Expensive Management (REM) Recipients: Not meeting criteria (See Pending Approval Section).
__Recipients not tube-fed, or without metabolic disorder, and under 5 years of age: Please contact the Women
Infants Children Program (WIC) at 1-800-242-4942 or 410-767-0298 for possible eligibility under this program.
___ Pending Approval of Payment for Nutritional Supplement
__ REM Recipients: Please have the Clinician submit the following information to the Program for an assessment
of the nutritional status of adult and pediatric recipients who are not tube-fed, or do not have an inborn error of
metabolism:
1. A comprehensive metabolic panel that includes prealbumin, serum Magnesium and Phosphorus levels if applicable.
2. A medical history documenting Patient’s undernutrition status with plan of care aimed at improving malnutrition status or optimizing outcome. Any weight loss incurred over the prior 6 month period must be documented (i.e. for AIDS patients).
3. Nutritional supplement orders for all recipients should be verified or recommended by a licensed nutritionist.
4. A mandatory Body Mass Index-for-age chart. Additional standard or clinical growth charts may be submitted but may not substitute for the required BMI-for-age chart. All charts must include updated measurements of weights and heights with corresponding dates.
___ Reasons for Rejection of Payment for Nutritional Supplement/Return of Form 3495 for missing information:
___Missing or unclear dosage/dosage form/dosage frequency/quantity/product NDC
___Missing length of nutritional therapy ___Unspecified percent tube-fed
___Missing conversion formula if prescribed in other units than billing units
___Ready-to-use formula not approved- Please select a non-premix form or submit reasons for needing the more
expensive ready-to use form of nutritional supplement.
___Missing Prescriber’s name, signature, and date signed
___Missing clinical data for determination of recipient’s nutritional status:___ pre-albumin level;
____serum Mg and Phos values;___ weight and height measurements; _____BMI-for-age chart.
___Other:______
Please resubmit nutritional supplement prior-authorization form with required information by fax or by mail to: Maryland Pharmacy Program- 201 W. Preston St., Room 409G- Baltimore, MD 21201
Fax #: 410-333-5398 - For all inquiries, call 410-767-1755
Form 3495B (Rev.03/2007) c:\MSWord\NutritionalsProviderNotif3495BApr2007.doc