945 Medical Assistance Program fee schedule; prior authorization requirements

Medical Assistance Program Fee Schedule; Prior Authorization Requirements

[37 Pa.B. 2463]
[Saturday, May 26, 2007]

   The Department of Public Welfare (Department) announces that effective July 2, 2007, prior authorization will be required on 11 enteral nutritional supplement procedure codes currently listed on the Medical Assistance (MA) Program Fee Schedule.

Prior Authorization Requirements

   The following procedure codes for enteral nutritional supplements will require prior authorization when prescribed to be administered orally without the use of a feeding tube for recipients 21 years of age or older, as authorized under section 443.6(b)(7) of the Public Welfare Code (code) (62 P. S. § 443.6(b)(7)) regarding reimbursement for certain MA items and services, as amended by the act of July 7, 2005 (P. L. 177, No. 42).

Procedure Code	Description	Informational Modifier
B4150	Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	BO
B4152	Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	BO
B4153	Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	BO
B4154	Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	BO
B4155	Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (such as, glucose polymers), proteins/amino acids (such as, glutamine, arginine), fat (such as, medium chain triglycerides) or combination, administered through an enteral feeding tube, 100 calories = 1 unit	BO

   Prior authorization is already required for procedure code B4157 when prescribed to be administered orally without the use of a feeding tube for recipients 21 years of age or older.

   The following procedure codes for enteral nutritional supplements will require prior authorization when prescribed to be administered either orally or through a feeding tube for recipients 21 years of age or older, as authorized under section 443.6(b)(7) of the code (62 P. S. § 443.6(b)(7)), as amended by the act of July 7, 2005 (P. L. 177, No. 42).

Procedure Code	Description	Informational Modifier as Applicable
B4103	Enteral formula, for pediatrics, used to replace fluids and electrolytes (such as, clear liquids), 500 ml = 1 unit	None
B4158	Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit	BO or None
B4159	Enteral formula, for pediatrics, nutritionally complete soy based with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber and/or iron, administered through an enteral feeding tube, 100 calories = 1 unit	BO or None
B4160	Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through a feeding tube, 100 calories = 1 unit	BO or None
B4161	Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	BO or None
B4162	Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit	BO or None

Fiscal Impact

   Although the prior authorization requirement is anticipated to result in savings to the Department, due to the relatively low volume of claims and minimal MA payments identified for these nutritional supplements, this change is expected to have minimal fiscal impact.

Public Comment

   Interested persons are invited to submit written comments regarding this notice to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received will be reviewed and considered in any subsequent revisions to the MA Program Fee Schedule.

   Persons with a disability who require auxiliary aid or service may submit comments using the AT&T Relay Services at [phone] (TDD users) or [phone] (voice users).

ESTELLE B. RICHMAN,   
Secretary

   Fiscal Note:  14-NOT-508. No fiscal impact; (8) recommends adoption.

[Pa.B. Doc. No. 07-945. Filed for public inspection May 25, 2007, 9:00 a.m.]