The Prior Authorization Request Form which includes the Certificate of Medical Necessity for Nutritional Therapy must be completed by the prescribing physician for all types of covered nutritional therapy ordered for Medicaid-eligible recipients.
Nutritional therapy suppliers (DME, physician or pharmacy) are to provide written documentation to support medical necessity and must complete the forms maintained in the patient's medical record prior to submitting a claim to Medicaid for payment.
To be medically necessary, the covered service must meet the following conditions:
Submit the completed form to:
Chapter 67:16:42: Nutritional Therapy and Nutritional Supplements:
67:16:42:02     Enteral nutritional therapy and nutritional supplements for individual under 21 years of age.
67:16:42:03     Enteral nutritional therapy for individual 21 years of age and older.
67:16:42:04     Enteral nutritional therapy for individual 21 years of age and older -- Prior authorization required.
67:16:42:05     Parenteral nutritional therapy.
67:16:42:06     Parenteral nutritional therapy -- Prior authorization required.
67:16:42:07     Nutritional therapy and nutritional supplements -- Limits.
67:16:42:08     Services not covered.