Adrienne Z Udarbe MS RDN Pinnacle Prevention Overview WIC Medical Documentation Review The Approval Process The AHCCCS Provider Family Continuum Why Medical Documentation and Approvals ID: 1038939
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1. Avoid Falling Down the WIC Formula Approval “Rabbit Hole”Adrienne Z. Udarbe, MS, RDNPinnacle Prevention
2. OverviewWIC Medical Documentation ReviewThe Approval ProcessThe AHCCCS – Provider – Family Continuum
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4. Why Medical Documentation and Approvals? WIC State agencies are required by law to have competitively bid infant formula rebate contracts with infant formula manufacturers.Manufacturers give the State agency a rebate for each can of infant formula purchased by WIC participants. The brand of infant formula provided by WIC varies by State agency depending on which company has the rebate contract in a particular State.By negotiating rebates with formula manufacturers, States are able to serve more people.
5. Medical DocumentationMedical documentation is required for issuance of the following supplemental formulas:Any non-contract brand infant formulaAny 19 kcal/oz formula including Similac Sensitive, Similac for Spit-Up, or Similac Total ComfortAny infant formula prescribed to a child or adultAny exempt infant formulaAny WIC-eligible medical food
6. Verbal Authorizations
7. IndicationsThe formula requested must be indicated for the medical condition and age of the client.
8. IssuanceGreen = Can always issue without rx.Yellow = Only RD and nutritionists can approve 1 month without script if client has been on the formula prior.Red = One month without prescription cannot be issued. Must contact the state for approval.Grey = Unable to issue.
9. Issuance, cont.For routine 19kcal/oz formulas (Similac Sensitive, Similac for SpitUp and Similac Total Comfort), 30 days’ worth of formula can be issued without a prescription. If a prescription is provided, the RD or nutritionist will provide the formula approval.
10. Incomplete DocumentationObtain missing information and document in the comment section of the Food Package screen of the HANDS system.
11. AHCCCSIf a participant requiring a special formula is participating in AHCCCS, it is the responsibility of the WIC nutritionist to review the criteria for AHCCCS special formula coverage and explain the process to the participant.
12. AHCCCS, cont.AHCCCS – Chapter 400: Medical Policy for Maternal and Child HealthPolicy 430: Early Periodic Screening Diagnostic and Treatment (EPSDT) ServicesIf an AHCCCS covered member qualifies for nutritional therapy due to a medical condition then AHCCCS Contractors are the primary payor for:Infant formulas above the amount provided through the WIC program or formula types deemed medically necessary that are not provided through the WIC program.This does not include formulas outside of those offered through the WIC program that are not medically necessary, such as formula types selected based on brand preference.WIC is considered a secondary payor.
13. AHCCCS, cont.EXHIBIT 430-2ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM CERTIFICATE OF MEDICAL NECESSITY FOR COMMERCIAL ORAL NUTRITIONAL SUPPLEMENTS (EPSDT AGED MEMBERS -INITIAL OR ONGOING REQUESTS)
14. AHCCCS, cont.7 Criteria for Medical Necessity: (Must meet 2 or more of the criteria)At or below the 10th percentile for age and gender for three months or more.Reached a plateau in growth or nutritional status for more than six months.Demonstrated a medically significant decline in weight for three months or more.Consumes/eats no more than 25% of his or her nutritional requirements from age appropriate foods.Absorption problems as evidenced by emesis, diarrhea, dehydration, and/or weight loss and intolerance to milk or formula products have been ruled out.Nutritional supplements needed on a temporary basis due to an emergent condition.High risk for regression due to chronic disease or condition and there are no alternatives for adequate nutrition.
15. EPSDT Coordinators1MERCY CARE PLAN602-263-3000http://www.mercycareplan.com2MERCY MARICOPA INTEGRATED800-564-5465http://www.mercymaricopa.org3CRS PARTIAL ACUTE800-348-4058http://www.uhccommunityplan.com4UNITEDHEALTHCARE800-348-4058http://www.uhccommunityplan.com5HEALTH CHOICE AZ480-968-6866http://www.healthchoiceaz.com6HEALTH CHOICE INTEGRATED877-923-1400http://www.healthchoiceintegratedcare.com7HEALTH NET ACCESS888-788-4408http://www.healthnetaccess.com8PHOENIX HEALTH PLAN602-824-3700http://www.phoenixhealthplan.com9DCS/CMDP602-351-2245https://www.azdes.gov/cmdp10MARICOPA HEALTH PLAN800-582-8686http://www.mhpaz.com11UNIVERSITY FAMILY CARE800-582-8686http://www.ufcaz.com12CENPATICO INTEGRATED CARE866-495-6738http://www.cenpaticointegratedcareaz.com13CRS FULLY INTEGRATED800-348-4058http://www.uhccommunityplan.com14CARE 1ST ARIZONA602-778-1800http://www.care1st.com
16. How WIC RD’s Facilitate This ProcessP&P Chapter 4 – WIC AHCCCS Formula Coverage Flow Chart
17. Pediasure ApprovalsA written medical authorization for PediaSure/Boost can be accepted and food instruments issued when at least one of the following conditions exist:Current assignment of Risk 103.1 (Underweight). Underweight definition for WIC: Birth to 2 years, less than or equal to fifth percentile weight for length. Two to 5 years, less than or equal to fifth percentile BMI for age. (Growth patterns are currently based on the 2000 CDC growth charts in HANDS.)Weight curve has crossed more than 2 percentile lines on the growth charts after having achieved a previously stable pattern. For example, the child has dropped from the 75th to the 25th percentile over time.Other medical conditions for the management of nutrition related disorders.Issuance of PediaSure/Boost requires the Local Agency nutritionist to: Complete a thorough screening and assessment as well as document all medical, nutrition, or psychosocial risk factors in the Care Plan in HANDS.Obtain a current height and weight for accuracy in growth screening criterion.Provide nutrition education on nutrient-dense foods to help promote weight gain.PediaSure/Boost cannot be issued in response to “picky eaters” or for the sole purpose of enhancing nutrient intake or managing body weight without an underlying condition.
18. Other Toddler Formula Approvals
19. Your Turn
20. Questions?