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Nutritional Supplement Pre-Authorization Form

DME Providers were sent the letter below and we have added it to the provider newsroom for reference. The following is a Maryland Medicaid Pharmacy Program Requirement.

RE: Nutritional Supplement Pre-Authorization Form

March 15th, 2020

Dear DME Provider:

Effective April 15th, Maryland Physicians Care will require all Durable Medical Equipment (DME) providers to complete and submit the Nutritional Supplement Pre-Authorization Form for any nutrition supplemental authorization requests. This is a Maryland Medicaid Pharmacy Program requirement for all enteral and parenteral formula approval(s).

The Nutritional Supplement Pre-Authorization Form will need to be completed in addition to the current Outpatient Medicaid Prior Authorization Form. If the completed forms are not submitted with your request for prior authorization, the approval review will take as many as 14 calendar days and may result in denial of services.

If the completed Nutritional Supplement Pre-Authorization Form is submitted with the pre-authorization request, the approval review will typically be completed within 2 business days.

After April 15th, 2020, Maryland Physicians Care WILL NOT authorize these services if the completed Nutritional Supplement Pre-Authorization Form is not submitted, in addition to the Outpatient Medicaid Prior Authorization Form

Prior Authorization Fax:  1.800.953.8856.

Please direct questions to Provider Services: 1.800.953.8854, Option 3

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