Library: Policy

317:30-5-211.20. Enteral nutrition

Revised 11-4-22

(a) Enteral nutrition. Enteral nutrition is the delivery of nutrients directly into the stomach, duodenum, or jejunum.

(b) Medical necessity. Enteral nutrition supplies must be determined by a provider to be medically necessary and documented in the member's plan of care as medically necessary and used for medical purposes. Requests by qualified providers for enteral nutrition supplies in and of itself shall not constitute medical necessity. The Oklahoma Health Care Authority (OHCA) shall serve as the final authority pertaining to all determinations of medical necessity. Refer to Oklahoma Administrative Code (OAC) 317:30-5-211.2 and 317:30-3-1(f) for policy on medical necessity.

(c) Documentation. All documentation submitted to request services must demonstrate, through adequate objective medical records, evidence sufficient to justify the member's need for the service, in accordance with OAC 317:30-3-1(f)(2). Documentation must include:

(1) Diagnosis;

(2) Certificate of medical necessity (CMN);

(3) Ratio data;

(4) Route;

(5) Caloric intake; and

(6) Prescription.

(7) For full guidelines, please refer to www.okhca.org/mau.

(d) Reimbursement.

(1) Extension sets and Farrell bags are not covered when requested separately from the supply kits;

(2) Enteral nutrition for individuals in long-term care facilities is not separately reimbursed as this is included in the per diem rate.

(e) Non-covered items. The following are non-covered items:

(1) Orally administered enteral products and/or related supplies;

(2) Formulas that do not require a prescription unless administered by tube;

(3) Food thickeners and infant formula;

(4) Pudding and food bars; and

(5) Nursing services to administer or monitor the feedings of enteral nutrition.