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Therapeutic Formula Training
Part 1
Presenter
Presentation Notes
Welcome to the Therapeutic Formula training webinar part 1 In Part 1 we will cover the process of Therapeutic Formula requests some of you are already familiar with the process but others may be new and we wanted a refresher course and more clarification of the process. This power point presentation as well as the notes from todays webinar will be posted on our Therapeutic Formula webpage In Part 2 we will cover Medi-Cal issues which will take place next spring of 2013 and additionally we will be sending out a survey by email to the attendees of this meeting and asking for other therapeutic formula topics you would like us to present on as well as feedback for this Webinar.
Agenda 1. Introductions 2. Federal Regulations Background 3. Therapeutic Formula Request Process
4. Current Issues 5. Resources
Presenter
Presentation Notes
State introductions: Denay Mintz processes the fax request and orders the Therapeutic Formula, Paula Etcheberry reviews and either approves or denies the request and Cheryl Barrios is the liaison for our State contacts at Medi-Cal Review Federal Regulations Background Steps of how to correctly process a therapeutic formula request Currents issues that have been coming up regarding therapeutic formula Show you resources that you can use to help with the process
ng
Objectives/Outcome Staff will increase their understanding of
Federal Regulations that govern Therapeutic Formula.
Staff will be able to identify the steps and locate resources for processi therapeutic formula requests.
Federal Regulations
WIC is the payor of last resort
7CFR 246.10 (e)(3)
Presenter
Presentation Notes
Federal regulations require coordination with other programs that provide formula, this requires referrals to other programs that provide formula and medical food. The WIC Program only provides Therapeutic Formula when other providers, such as Medi-Cal, have denied the request While WIC is the payor of last resort we do provide coverage while a participant is in process of applying to Medi-Cal or other programs that would provide Therapeutic Formula.
there is a documented qualify ng condition for the formula; and
ion; when formula i
provider
7CFR 246.10 (e)(3)
Federal Regulations Therapeutic Food Packages can be issued
when: i
supported by medical documentat s not provided by another
Presenter
Presentation Notes
The medical documentation is provided by the medical provider on a completed Pediatric Referral Form. Reminder: WIC is the payer of last resort. These requirements outlined as part of the federal regulations are in place both when the therapeutic formula is provided on our food instrument or is ordered from State WIC.
Qualifying conditions Include but are not limited to: Severe Food Allergies GI Disorders Prematurity Low Birth Weight Failure to Thrive
cal Documentation
amount needed per day; me the prescribed formula
ng condition(s) for the issuance of
signature, date, and contact information of licensed by the State to wr
Medi Must include: name of Formula;
length of ti is required;
the qualifyi the formula; and
the professional ite prescription
Federal Regulations (continued) Therapeutic Formula Packages CANNOT
be issued for food/formula intolerance or food allergy
that does not require an exempt formula; or
solely for enhancing intake or managing body weight without an underlying qualifying condition
Presenter
Presentation Notes
Example of possible use for solely enhancing intake or managing body weight: e.g., as when child has experienced a recent growth spurt. Medical provider prescribed PediaSure as mom states he doesn’t seem to be eating as much and his weight hasn’t increased as he has grown. What do you do? Don’t ignore the Rx, contact the provider’s office: Explain WIC does not provide PediaSure (a WIC therapeutic formula) without a qualifying condition. Is there a specific dx-qualifying condition? If YES, need a completed Pediatric Referral Form indicating the qualifying condition and follow the therapeutic formula process which will be outlined. If NO, inform that WIC is not authorized to provide PediaSure but the WIC RD can work with caregiver and offer suggestions on using WIC foods to increase participant’s intake.
Questions What are your questions regarding the
Federal Regulations about Therapeutic Formula?
Who provides Therapeutic Formula? Refer participant to Medi-Cal and/or other
programs that provide therapeutic formula WIC is the payor of last resort
Presenter
Presentation Notes
If the participant has Medi-Cal, work with them to make sure they have submitted their prescription to Medi-Cal. If they do not have Medi-Cal, have them apply and document status updates in ISIS family comments. If the participant is reluctant to apply for Medi-Cal, work with them and have a conversation with them to find out why they are not applying For example: in the cases of participants with private insurance, they may think they will lose coverage with their insurance if they apply for Medi-Cal. This is not true. Medi-Cal will cover the Therapeutic Formula and the participant can keep their private insurance. In fact, Medi-Cal requires their denial letter from their private insurance before they will cover their therapeutic formula. Document reason participant is reluctant to apply for Medi-Cal in ISIS family comments Remember WIC is the payor of last resort for therapeutic formula
Therapeutic Formula Process
Participant has a prescription
WIC
Local Agency
Process
Food Package
State
Order Formula
Food Package
Other Provider
Food Package
Presenter
Presentation Notes
Here is a visual of the Therapeutic Formula process that incorporates other providers as well as WIC The therapeutic formula request process starts when a participant gets a prescription for a Therapeutic formula A majority of the participants should be receiving Therapeutic Formula from another provider such as Medi-Cal, then we will provide the WIC foods where the food package would include the WIC foods but no formula
What Food Package do I issue when formula is provided by another provider?
Category FD PKG ID Infant (0-3 mo.) IF1P Infant (4-5 mo.) IFQP Infant (6-11 mo.) IF2P Infant, 1st Birthday IT4P Child (12-23 mo.) CT4P Child (24 mo. - 5 yrs.) CF4P
Presenter
Presentation Notes
If the participant is receiving therapeutic formula from another provider such as Medi-Cal or CCS You can issue these different food packages by age as shown on this slide As you can see at the end of these food package ID is the letter P, this is to stand for other provider to make it easier for you to remember when issuing these food packages It is important to use the correct food package because Therapeutic Formula rates are based on the type of food package issued
Therapeutic Formula Process
Participant has a prescription
WIC
Local Agency
Process
Food Package
State
Order Formula
Food Package
Other Provider
Food Package
Presenter
Presentation Notes
If the participant is receiving Therapeutic Formula from WIC, whether it is printed on Food Instruments (FI) or if the request is sent to State WIC, the process is the same and the correct food package is then issued
Local Agency Process Obtain required documentation Document in WIC MISIssue Food Package and/or Therapeutic Formula
Presenter
Presentation Notes
At the local agency level the process is to (read bullets) Also to maintain a file (electronic or hard copy) of all medical documentation and have in a place readily accessible for program evaluations and audit purposes (this will be in the revised WIC policy).
Obtain required documentation
Determine if the formula matches the diagnosis
Pediatric Referral Form
Presenter
Presentation Notes
If a participant comes into the clinic with a prescription for a therapeutic formula, they should be scheduled to see the dietitian where a determination is made whether the diagnosis fits the formula If the diagnosis does not match the formula, please contact the provider and talk to them about what formula would be appropriate for the baby or child For additional information on formulas, please refer to our Therapeutic Formula website or the formula product guide Make sure the participant has the proper paper work that should include the Pediatric Referral Form # CDPH 247A completely filled out, and any other medical documentation from the doctor’s office. Obtain a new Pediatric Referral form at six months and one year of age that includes food restrictions.
Presenter
Presentation Notes
Here are two examples of the Pediatric Referral form, as you can see the one on the left is completely filled out and ready to go The one on the right however is missing important information If food allergy is marked, we need to know what foods the participant is allergic to The duration as well as the amount per day must be filled out and whether it is a new prescription or a refill Make sure to include the type of insurance the participant has and what referrals the doctor has made
WIC MIS Documentation State why Therapeutic Formula is needed
List other formulas participant has tried and not tolerated
Follow up plan Medi-Cal status
Presenter
Presentation Notes
Remember that your fellow local agency staff as well as others will need ISIS documentation for follow-up on the participant. Document the Rx & Dx (the qualifying condition) in comments or INEP and be sure to identify the appropriate ISIS Risk Code (e.g., food allergy, FTT). Be specific; often we see food allergy but the specific foods are not identified. If previously on another formula, document reason for the formula change. Document what the F/U plan is to monitor tolerance with this formula. If new formula Rx, how is tolerance to be monitored? Follow-up should also include updates on weights/lengths/heights and status on general intake if taking other foods. Medi-Cal Status: If referred, do they plan to apply? If not, what are their concerns/what assistance was offered?
Therapeutic Formula printed on Food Instruments (FIs):
For premature babies:
For term babies: For toddlers:
Presenter
Presentation Notes
For therapeutic formula that is on an FI, you can print out a one month supply and have them follow up with Medi-Cal for formula coverage. There are five therapeutic formulas that are printed on FIs and available for participants with a prescription For premature babies there is Enfamil Enfacare and Similac Expert Care NeoSure Powder For term babies with allergies there is Nutramigen Concentrate and Similac Expert Care Alimentum Powder For toddlers with failure to thrive there is Pedia Sure, Vanilla Ready to Feed
What Food Package do I issue when formula is printed on FI?
Category FD PKG ID Infant (0-3 mo.) IF1A Infant (4-5 mo.) IFQA Infant (6-11 mo.) IF2A Infant, 1st Birthday IT4A Child (12-23 mo.) CT4A Child (24 mo. - 5 yrs.) CF4A
Presenter
Presentation Notes
If the participant is getting therapeutic formula that is printed on an FI You can issue these different food packages by age as shown on this slide As you can see at the end of these food package ID is the letter A, this stands for Agency as in local agency to make it easier for you to remember when issuing these food packages
Therapeutic Formula through CA State WIC
Refer the request to State WIC for formulas not printed on FIs
Fax request to (916) 440-5581
Presenter
Presentation Notes
For formula that is not printed on an FI, fax the request to CA State WIC at 916-440- 5581, include the Pediatric Referral Form # CDPH 247A completely filled out with a fax cover sheet that includes your contact information as well as shipping address to where you want the formula to be shipped. Document in ISIS and maintain a file (electronic or hard copy) of all medical documentation and have in a place readily accessible for program evaluations and audit purposes. This file shall include a WIC Pediatric Referral Form # CDPH 247A, all faxes sent or received, and denial letters from other medical payers.
California State WIC Process
State WIC Review Approved or Denied
Presenter
Presentation Notes
Once CA WIC has received a completed form with your local agencies’ information, the request is then processed and forwarded to the RD for approval or denial. If there is incomplete information, this make the process longer and you will get a call from CA WIC. Once the RD gets the paperwork for review, they either approve or deny the request. If the request is denied, you will receive a fax stating the reason for the denial. If the request is approved, it will be processed.
State WIC Ordering Process Order is placed Received Estimated Time of Arrival (ETA) Process takes approximately 5-7 business
days
Presenter
Presentation Notes
The order is placed with the formula company CA WIC receives an estimated time of arrival (aka ETA) of when it will be shipped to you at the local agency. Once CA WIC gets the ETA, it is then faxed to you at the local agency on the transmission sheet which will include the ETA, so you will know when to expect the delivery of the formula. This process with review and ordering, as long as we receive the correct and complete paperwork takes approximately 5-7 business days.
FA X
SHEET
Presenter
Presentation Notes
This is an example of the fax sheet that is faxed to the local agency At the top of the form will be your contact name, email if provided, phone number and fax number The next section includes the participants name, the formula requests, whether it was approved or denied, who reviewed it, the amount of cases for how many months, the maximum # of cans allowed per month by age and our comments. The maximum cans per month is determined by their age, this should be the number of cans issued per month to the participant and they should not receive more than the maximum cans per month The comments section of this form is important because that’s where we give instructions on follow up. At the bottom of the fax sheet is a signature receipt confirming the participant has received the Therapeutic Formula for that month. The participant signs this portion and this form is kept for your records.
issue when ides the formula?
What Food Package do I state WIC prov
Category FD PKG ID Infant (0-3 mo.) IF1G Infant (4-5 mo.) IFQG Infant (6-11 mo.) IF2G Infant, 1st Birthday IT4G Child (12-23 mo.) CT4G Child (24 mo. - 5 yrs.) CF4G
Presenter
Presentation Notes
If the participant is getting therapeutic formula from CA State WIC You can issue these different food packages by age as shown on this slide These are the packages you will use after you have sent over your request to State WIC. As you can see at the end of these food package ID is the letter G, this stands for Government , this indicates that it is provided by State WIC and makes it easier for you to remember when issuing these food packages Again remember it is important to use the correct food package because Therapeutic Formula rates are based on the type of food package issued. The food packages for therapeutic formula only end in either a P for Other Provider, A for Local Agency and G for Government meaning State WIC
Questions What are your questions regarding the
Therapeutic Formula request process?
Current Issues Contract vs. Noncontract formula Ready-to-Feed formula Nutramigen and Nutramigen with Enflora LGG
PediaSure Availability of formula products in stores
Presenter
Presentation Notes
Now let’s talk about issues that come up related to therapeutic formula process.
Contract vs. Noncontract Formulas
California WIC contracts with Mead Johnson for iron fortified standard formula
Standard products from other companies are not authorized by California WIC
Presenter
Presentation Notes
We have received questions about requests for non-contract standard formulas both as a caregiver preference and as a prescription. If caregiver preference: Document reason mom doesn’t want the contract formula. If a nonspecific reason is given such as prefers to use a non-contract standard formula started in the hospital. Explain that the Mead Johnson formula we offer is Enfamil. Review feeding practices. Provide suggestions on weaning from one product to the one we offer for optimum tolerance. Materials on weaning such as: Changing to a New Formula are on the CA WIC website/WIC Local Agencies/Formula/Information for Registered Dietitians. If there is a prescription, don’t ignore the prescription. Contact the medical provider: Explain that WIC does NOT provide the prescribed formula but that the Mead Johnson formula we offer is Enfamil. If change is acceptable, we will provide suggestions on weaning from their current formula to our contract formula to ensure optimum tolerance. If NOT acceptable, explain that caregiver will have to obtain from another source other than WIC, unless there is a qualifying condition suggesting use of an appropriate therapeutic formula.
Ready-to-Feed Can only be issued under the following
conditions: unsanitary or restricted water supply; poor refrigeration; or caregiver has difficulty in correctly
diluting powder or concentrate
Presenter
Presentation Notes
Only if criteria met: Unsanitary or restricted water supply or poor refrigeration Person caring for participant may have difficulty in correctly diluting concentrated or powder forms The exception is PediaSure which is Ready-to-Feed If you receive a prescription that does not appear to meet the criteria: Do NOT ignore the Rx. Follow-up with the caregiver and the medical provider and let them know that the Ready-to-Feed form is being denied and why. Explore any other options. If prescribed and the criteria is met: Process as a therapeutic formula request with completed documentation sent to the state to order.
Nutramigen and Nutramigen with Enflora LGG What would you do if you received a
prescription for Nutramigen Powder??
Presenter
Presentation Notes
Nutramigen used to come in powder and concentrate forms Mead Johnson no longer makes the Nutramigen in powder so now only available in concentrate. We provide Nutramigen concentrate on our FI as a therapeutic formula. Nutramigen Enflora LGG is a totally different product than Nutramigen. If you receive a prescription for Nutramigen w/Enlfora LGG, DO not substitute with Nutramigen concentrate without a change in prescription. .
PediaSure PediaSure is over prescribed
Failure to thrive (FTT) diagnosis
Other options
Presenter
Presentation Notes
Issues have been coming up with PediaSure at the local level. Participants are coming in with prescriptions for PediaSure with a dx of Failure to Thrive (FTT) even when the child is consistently >95%BMI. What do you do if in your assessment FTT does not appear to be a current condition and PediaSure is not indicated? Call the medical provider and talk to them about other options if it is not a true FTT. Explain WIC does not provide PediaSure without a qualifying condition and inform the provider that WIC is not authorized to provide PediaSure but the WIC RD can work with caregiver and offer suggestions on using WIC foods to increase participant’s caloric intake. If after talking with the medical provider, PediaSure is indicated and there is a qualifying condition, follow the therapeutic formula process. Remember: Therapeutic formula is not solely for the purpose of enhancing nutrient intake or managing body weight without an underlying qualifying condition.
Availability of formula products in stores Work with the vendor Work with pharmacy within an authorized
WIC vendor Find another authorized WIC vendor
Presenter
Presentation Notes
Things you can do when availability of formula in the store is an issue. Situation: Caregiver comes to you about difficulty finding the formula in the form or the amount needed. What do you do? Have the participant work with their current WIC authorized vendor to see if they can order the formula Additionally you can go into the formula companies website for formula product availability and use their product finder search tool to provide a caregiver a list of which stores carry the product. If a caregiver inquires about a store from this list, you may call the store to make sure they are WIC authorized and verify that they have the formula in stock for the caregiver. If the formula is a therapeutic product, the participant can check with the pharmacy within their WIC authorized vendor to see if the formula they need is on the pharmacy’s list and if they can order it with a prescription
Questions What are your questions regarding the
current issues we just went over?
Resources on our Website
Presenter
Presentation Notes
You can find resources on our website For Therapeutic Formula, this page can be found from our home website under WIC Local Agencies, under the Formula title The Job Aid with all the food packages by age that lists all the WIC foods in specific detail can also be found under WIC Local Agencies, under the ISIS title at Job Aid Basic Food Package Description for WIC Authorized Food List Shopping Guide.
Therapeutic Formula Webpage
Presenter
Presentation Notes
This is what the Therapeutic formula website looks like At the top you see Procedures, under procedures there are a number of items First is the Process for Therapeutic Formula Request which tells you what we went over today The Pediatric Referral Form is what the doctor fills out with the prescription and is a requirement when requesting therapeutic formula from the state Infant and child screening forms that are not required but are very helpful with the process Then we have our policies regarding therapeutic formula and also a helpful source called common indications for Therapeutic Formula On the bottom left hand side are product links for the major formula companies, these links will take you directly to the formula products On the bottom right hand side we have Insurance Resources which will take you to the different sources that can also help the participant with services
Partnering with Medi-Cal The WIC program partners with State
Medi-Cal to:
strengthen communication work towards solving issues
Presenter
Presentation Notes
We at State WIC partner with State Medi-Cal staff to strengthen communication between our two programs As Local Agencies bring situations to our attention, we are able to share them with our contacts at Medi-Cal to see how the situations can be resolved. We look for trends and send in specific case(s) to the State Medi-Cal contact in the Enteral Division. They will then advise us of the outcome. For example: In August, 2012, we received information concerning Shield HealthCare, a large mail order Pharmacy that provides services to many of our rural WIC participants currently on Fee For Service Medi-Cal The Local Agency staff informed us that they were being told by Shield HealthCare that they were refusing to serve children aged 5 years and younger. Cheryl worked closely with an RD at one of our Local Agencies, obtained detailed information on a specific participant,who was denied service from this mail order pharmacy Cheryl then forwarded this information to our contacts at Medi-Cal for assistance. They provided us with 3 more names of mail order pharmacies in the area that could provide the therapeutic formula to these participants. This example emphasizes the importance of local agencies providing detailed information to State WIC so that we can work with Medi-Cal. State WIC staff will continue to work with the Medi-Cal state staff and as the issues are resolved, the outcome will be conveyed to the local agencies.
Contact Information [email protected] (916) 928-8762 [email protected] (916) 928-8539 [email protected] (916) 928-8579
Therapeutic Fax: (916) 440-5581
Presenter
Presentation Notes
If you have any additional questions after this webinar, please contact us at the contact information above: For therapeutic formula requests contact Denay Mintz or Paula Etcheberry For Medi-Cal challenges contact Cheryl Barrios
Follow up Survey Monkey
Therapeutic Formula Training, Part 2 Spring 2013 Medi-Cal challenges
Presenter
Presentation Notes
In the following weeks, California State WIC will be sending out a survey to the attendees of this webinar by email asking for other therapeutic formula topics you would like us to present on as well as feedback for this Webinar. The Part 2 training will take place in Spring of 2013 and we will discuss Medi-Cal challenges as well as any other topics from the survey Thank you for attending our webinar. Hopefully this information is helpful for you and your staff when a participant comes in your clinic with a Therapeutic Formula request.