Policy and Procedure Manual

Volume 1, Chapter 24 Medical Documentation for Formulas and Foods Washington WIC Program DOH 960-367 REQUIRED GUIDANCE – Effective July 14, 2025

REQUIRED GUIDANCE

This institution is an equal opportunity provider. Washington WIC doesn’t discriminate.

For persons with disabilities, this document is available on request in other formats. To submit a request, please call 1-800-841-1410 (TDD/TTY 1-800-833-6388).

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REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods | Page i

Medical Documentation for Formulas and Foods

CONTENTS Section 1: Definitions 1 Section 2: General Requirements 2 REQUIRED GUIDANCE: General Requirements for Providing Therapeutic WIC Formulas and Foods .................................................................................................. 2 REQUIRED GUIDANCE: Provide Therapeutic WIC Formulas and Foods ................................... 7 REQUIRED GUIDANCE: Deferral to the Registered Dietitian Nutritionist for WIC Foods ......... 9 REQUIRED GUIDANCE: Transfer Participants Needing Therapeutic WIC Formulas and Foods ......................................................................................................... 11 Section 3: Provide Medical Foods and/or Medical Formulas 12 REQUIRED GUIDANCE: Inform Participants about the Process to Receive Formulas and/or Nutrition Products from Medicaid, TRICARE, Private Health Insurance and Other Providers ......................................................................... 12 REQUIRED GUIDANCE: Complete the WIC/Medicaid Nutrition Form ................................... 14 REQUIRED GUIDANCE: WIC Benefits Provided to WIC Participants Receiving Formulas and/or Nutrition Products from Medicaid, TRICARE, Private Health Insurance or Other Providers ........................................................... 16 REQUIRED GUIDANCE: Provide Medical Foods and Medical Formulas through WIC ............ 17

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REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods | Page 1 Section 1: Definitions

Definitions:

Standard contract formula: Infant formula that is not intended for infants with medical or dietary conditions and does not require medical documentation for infants 0 through 11 months (unless the infant requires the “No infant foods” food package, in which case complete medical documentation for the WIC formula is required). • Standard contract formulas provided on the WIC card: Similac Advance, Similac Sensitive, Similac Total Comfort, and Similac Isomil.

Standard non-contract formula: Infant formula that is not intended for infants with medical or dietary conditions but requires medical documentation. • Standard non-contract formula provided on the WIC card: Enfamil AR.

Therapeutic formula: Infant formula that is intended for infants with medical or dietary conditions and requires medical documentation. • Therapeutic formulas provided on the WIC card: Similac NeoSure, Enfamil NeuroPro EnfaCare, Similac Alimentum, and Enfamil Nutramigen LGG.

WIC Eligible Nutritionals: Products that are designed to provide nutritional support for individuals with a qualifying condition, when the use of conventional foods is restricted or inadequate. These products require medical documentation. • WIC Eligible Nutritionals provided on the WIC card: PediaSure and PediaSure with Fiber.

Therapeutic food: Food that is not provided in the standard food prescription for a specific participant and age category. • Examples of therapeutic foods provided on the WIC card: o Infant cereal and infant fruits/vegetables for participants ≥ 1 year old o Whole milk for participants ≥ 2 years old

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| Page 2 REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods Section 2: General Requirements

REQUIRED GUIDANCE: General Requirements for Providing Therapeutic WIC Formulas and Foods

1. The Competent Professional Authority (CPA) must assess a WIC participant’s nutritional needs and determine an appropriate WIC food prescription.

• Medical documentation for WIC formulas, foods, or WIC Eligible Nutritionals (WENs) (ex. PediaSure) must be reviewed by WIC staff for completeness.

• WIC staff must ensure that the medical documentation meets the requirements below and that the qualifying diagnosis is consistent with the manufacturer's recommended usage of the prescribed food or formula.

• See Volume 1, Chapter 23 – WIC Foods for more information.

2. Staff must assess the likelihood that a participant has a qualifying medical diagnosis (such as those listed on the WIC Medical Documentation Form - MDF) before providing the MDF to participants or caregivers.

Tip: It can be helpful to fill in the clinic’s contact information on the bottom of the MDF and have the participant sign the Release of Information (ROI) if they are present in the clinic.

3. Requests for formulas, foods, and WENs requiring medical documentation can be submitted on an MDF or other medical documentation format as long as the medical documentation includes all required elements as described in this policy. • Examples of acceptable medical documentation include (but are not limited to):

a. The prescription pad of a health care provider with prescriptive authority.

b. Discharge paperwork from the hospital when signed by a health care provider with prescriptive authority.

c. Older versions of the MDF. • Staff may print the MDF from the Washington State WIC Nutrition Program website at: https://doh.wa.gov/you-and-your-family/wic/wic-foods/wic-infant- formula.

4. Complete medical documentation MUST include all of the following information:

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a. First and last name of the participant receiving the formula, food, or WEN.

b. Name of prescribed formula, food, or WEN.

c. Qualifying diagnosis that is consistent with the manufacturer’s recommended usage of the requested formula, food, or WEN. • For example: A prescription for Neosure with a diagnosis of milk protein allergy shouldn’t be accepted. The health care provider should be contacted to investigate whether an appropriate diagnosis exists for the prescribed formula.

Note: Symptoms aren’t acceptable as qualifying medical diagnoses for WIC. Symptoms include colic, constipation, vomiting, spitting up, rash, fussiness, picky eating, or food or formula refusal.

d. Amount needed per day of the prescribed formula, food, or WEN.

Note: When therapeutic foods (i.e. infant cereal and infant fruits/vegetables for children or adults) are indicated on the medical documentation, provide the maximum amounts unless the health care provider specifies a reduced amount.

e. Duration of prescription. • Medical documentation must only be approved for a maximum of 6 months. Medical documentation written for longer durations may be approved up to 6 months but not longer. This encourages regular follow- up with the health care provider to help ensure the participant doesn’t continue receiving a medical food or formula longer than is appropriate given the medical diagnosis.

f. Signature, date, and contact information of a health care provider with prescriptive authority.

• In WIC, the most common prescriptive authorities include physicians (MD), physician assistants (PA), naturopaths (DO), and advanced registered nurse practitioners (ARNPs). • Electronic, faxed, or original forms are acceptable.

5. Staff have the option to:

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| Page 4 REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods a. Contact the participant’s health care provider to obtain a verbal order or to obtain missing information or clarification on the medical documentation if the participant has signed an ROI.

• Document any contact made with the participant’s health care provider in the Individual Care Plan. Include the following information:

o Name of the person contacted at the health care provider’s office.

o Any important information about a prescription or the diagnosis or medical condition (for example follow-up plans, special feeding instructions, corrections to make on the medical documentation).

o Date of the contact.

o Contact information of the health care provider with prescription writing authority in the state of Washington.

Note: If the health care provider isn’t available, the health care provider’s staff can relay messages back to WIC staff as long as the message comes from a health care provider with prescription writing authority in the state of Washington.

• Issue up to only one month of formula with verbal orders until medical documentation can be obtained.

Note: See the Cascades Steps Enter Verbal Order For Medical Documentation Form for instructions on entering a verbal order into Cascades.

b. Access the electronic medical record when the WIC clinic is integrated into a medical facility and obtain the health care provider’s formula order (only when the local agency has a policy for WIC staff to access the electronic medical record). Issue one month of formula until medical documentation is obtained.

Note: Staff must request that medical documentation be provided within 2 weeks of obtaining a verbal order or reviewing an electronic medical record. Staff must update the Medical Documentation section of Cascades as needed.

6. WIC staff must obtain medical documentation in the following situations:

a. Any newly prescribed formulas, foods, and WENs, including:

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REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods | Page 5 • Therapeutic formula, therapeutic foods, or WENs for any participant category. • Infants requiring the increased formula package (no baby foods) at ≥ 6 months of age with therapeutic or standard formula. • Participants 1 year or older requiring a standard formula.

b. Changes to currently prescribed formulas, foods, or WENs, including: • One therapeutic formula or WEN to another. • Therapeutic formula to standard formula. • Infant cereal to breakfast cereal or infant fruits and vegetables to standard CVB.

c. Current medical documentation expires and there’s still a medical need for the formula, food, or WEN.

d. A participant’s category changes and there’s still a medical need for the formula, food, or WEN.

Note: When medical documentation is in effect, staff can’t make changes to prescribed formula, food, or WENs without receiving approval from the health care provider.

7. Staff must assign a nutrition risk factor in Cascades based on the qualifying medical diagnosis on the medical documentation.

8. Staff must assess the amount of formula required to meet the participant’s nutritional needs, considering the amount prescribed by the health care provider, the participant’s breastfeeding status, and any relevant nutritional or health information.

9. Caregivers or participants may complete the ROI section of the MDF (Box 6) allowing WIC staff to contact the health care provider with questions. Signing this form is optional for the caregiver or participant, but if Box 6 is not completed, the WIC agency’s ROI is required for staff to share participant information with the health care provider.

10. In the Attach Medical Documentation section of the Food Prescription screen, scan the medical documentation into Cascades using the Scan Document button.

a. See the following staff tools for step-by-step instructions: • WIC Cascades Steps - Enter Medical Documentation for the First Time

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| Page 6 REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods • 961-1171-Enter New Medical Documentation When Current Medical Documentation Exists • 961-1290- Enter Verbal Order For Medical Documentation Form • 961-1251-Medical Documentation to Provide Infant Fruits and Vegetables to Children

Note: If the health care provider indicates a timeframe (ex. 3 months) rather than an expiration date, the expiration date should be entered as the last day of the final month in which the prescribed benefits are issued.

For example: If the health care provided wrote the medical documentation for 3 months and the prescribed product will be issued on the participant’s January, February, and March benefits, then the expiration date should be March 31st.

b. Once staff has scanned the medical documentation into Cascades, it can be shredded or given back to the participant if desired.

Information:

WIC federal regulations don’t allow staff to provide therapeutic WIC formulas and foods as a consideration to meet a participant’s cultural or personal preferences.

See “Provide Medical Foods and Medical Formulas through WIC” in this chapter when participants need medical foods or formulas that aren’t available from WIC.

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REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods | Page 7 REQUIRED GUIDANCE: Provide Therapeutic WIC Formulas and Foods

Considerations for Infants:

1. See Volume 1, Chapter 23 – WIC Foods for information on Ready-To-Feed formula.

2. Schedule an appointment with the caregiver before the infant turns 6 months old to assess readiness for infant foods and determine the appropriate food prescription.

3. Assign infant foods unless the health care provider indicates they aren’t allowed.

• Staff can only issue additional formula instead of infant foods (the amount in the 4-5 month food prescription) with complete medical documentation.

o The healthcare provider must indicate “No infant foods (issue additional formula)” and complete Boxes 2 and 3 on the Medical Documentation Form OR

o Provide alternate medical documentation that indicates the need for formula only; the formula name, amount, and duration; and a qualifying medical diagnosis (see “General Requirements for Providing Therapeutic WIC Formulas and Foods” for general medical documentation requirements).

4. Refer to “Deferral to the Registered Dietitian Nutritionist (RDN) for WIC Foods” when the health care provider defers prescribing infant foods to the RDN.

5. Before the first birthday, discuss child food prescription options with the caregiver and provide an MDF if a therapeutic formula, food, or WIC Eligible Nutritional (WEN) may be needed beyond 1 year of age.

Note: PediaSure is designed for children 2 to 13 years of age. Consult the health care provider when children under 2 years of age are prescribed PediaSure.

Considerations for Participants 1 Year and Older:

1. Complete medical documentation is required before issuing:

• Infant fruits and vegetables or baby cereal for participants 1 year and older.

o If the health care provider prescribes infant fruits and vegetables, staff may NOT issue any of the fruit and vegetable Cash Value Benefit (CVB).

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o If the health care provider prescribes infant cereal, staff may NOT issue the breakfast cereal benefit.

• Whole milk or whole milk yogurt for participants ages 2 years and older (if the health care provider deferred foods to the RDN on the medical documentation, the RDN may approve whole milk yogurt if appropriate).

• See Volume 1, Chapter 23 – WIC Foods for more information.

2. Refer to “Deferral to the Registered Dietitian Nutritionist for WIC Foods” when the health care provider defers prescribing foods.

3. Staff may not issue participants diagnosed with a severe food allergy (including milk protein allergies) any food that causes an allergic reaction.

• If allergenic foods aren’t marked as not allowed contact the health care provider for clarification and document the discussion in the Individual Care Plan.

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REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods | Page 9 REQUIRED GUIDANCE: Deferral to the Registered Dietitian Nutritionist for WIC Foods

1. The health care provider may defer the responsibility of prescribing WIC foods and the amounts of food to the Registered Dietitian Nutritionist (RDN).

2. WIC federal regulations don’t allow the health care provider to defer prescribing formula to the RDN.

3. WIC federal regulations only allow this deferral for an RDN working in the WIC Nutrition Program and not to RDNs outside of WIC.

PROCEDURE:

When the health care provider defers the responsibility of prescribing WIC foods to the RDN, the RDN:

A. Talks with the caregiver or participant to determine which foods are appropriate based on the participant’s medical diagnosis or medical condition.

B. Makes the appropriate changes to the prescribed WIC foods and the amounts during the time specified on the prescription.

C. Can’t prescribe foods causing allergic reactions without the approval of the health care provider.

D. Contacts the health care provider if the medical documentation doesn’t allow foods that the RDN thinks are medically appropriate (a Release of Information is required to contact the health care provider).

E. Documents the discussion with the caregiver and authorization for the deferral in the Individual Care Plan. Includes the following information in the documentation: • Deferral to the RDN. • The name of the RDN. • The date the RDN entered the note, if the note was entered at a later date.

Example: “Foods deferred to Mary Smith, RDN, 10-31-25.”

F. Enters the medical documentation into Cascades using the Medical Documentation button on the Food Prescription screen and documents the medical documentation in the Individual Care Plan.

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G. When the RDN isn’t available to speak with the caregiver or participant, staff can’t issue WIC foods.

1. Staff only issues benefits for the formula prescribed by the health care provider.

Note: Staff may also contact the health care provider (if the participant signs a Release of Information) for guidance on issuing WIC foods if the RDN is not available.

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REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods | Page 11 REQUIRED GUIDANCE: Transfer Participants Needing Therapeutic WIC Formulas and Foods

1. Staff must follow WIC policies and procedures for transfer participants.

• See Volume 1, Chapter 21 - Transfers.

2. Medical documentation is required for therapeutic formulas (including WIC Eligible Nutritionals - WENs) and foods (see “General Requirements for Providing Therapeutic WIC Formulas and Foods”) when participants transfer from another WIC clinic. Medical documentation from the previous WIC clinic meets this requirement.

a. In-State Transfers: Medical documentation from in-state transfers may be accepted up to the duration of the prescription.

b. Out-of-State Transfers: Medical documentation from out of state may be accepted for up to 3 months but not exceeding the original expiration date, to allow the participant time to obtain a new medical provider.

3. When medical documentation is not available from the previous clinic, staff may contact the health care provider to request the medical documentation. A Release of Information (ROI) is required.

4. If staff cannot obtain the medical documentation from the previous WIC clinic or health care provider, then staff may ask the participant to get new medical documentation from their health care provider.

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| Page 12 REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods Section 3: Provide Medical Foods and/or Medical Formulas

REQUIRED GUIDANCE: Inform Participants about the Process to Receive Formulas and/or Nutrition Products from Medicaid, TRICARE, Private Health Insurance and Other Providers

Staff must inform participants about the process of requesting formulas and/or nutrition products from Medicaid, TRICARE (military health insurance provider), the participant’s health insurance provider, or other providers when:

1. The person is not WIC eligible. Or 2. The health care provider prescribes a formula and/or nutrition product the Washington State WIC Nutrition Program doesn’t provide. Or 3. The health care provider prescribes additional formula and/or nutrition product above WIC’s maximum amount.

PROCEDURE:

Staff:

A. Inform the participant what steps to take to request formulas and/or nutrition products from Medicaid.

Note: Staff can use the “Process to Request Formula from Medicaid” document and the “WIC Clinic Response to Formula Requests” flow chart to help explain the process. Staff can copy these documents from the Appendix of this chapter or print them from the Washington State WIC Nutrition Program web site: https://doh.wa.gov/you-and-your-family/wic/wic-foods/wic-infant-formula

1. If the participant is eligible to receive a formula and/or nutrition product from Medicaid and has private health insurance which would cover the formula and/or nutrition product, Medicaid would require the private health insurance provider to supply it.

Note: If the participant’s private health insurance doesn’t provide the formula and/or nutrition product, then Medicaid may provide it. Medicaid requires a statement from the private health insurance provider stating they won’t provide the formula and/or nutrition product to the participant.

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B. Inform participants they can receive WIC foods at the same time they receive a formula and/or nutrition product from Medicaid. Medicaid only allows a WIC participant to receive formula from Medicaid and WIC at the same time when the participant needs more than the maximum amount provided by WIC.

• See the “WIC Benefits Provided to WIC Participants Receiving Formulas and/or Nutrition Products from Medicaid, TRICARE, Private Health Insurance or Other Providers” policy in this chapter.

C. Participants who have military health insurance (TRICARE) must first go to TRICARE before going to Medicaid to request:

1. A formula that the WIC Program doesn’t provide, or

2. Additional formula above WIC’s maximum amount.

Notes:

• TRICARE should pay for formulas and/or nutrition products if they are on their formular list and if the ordering physician gives medical justification. These specialty formulas are listed at the following web addresses: https://www.dmepdac.com/dmecsapp/.

• Refer to the specific information pertaining to the benefits provided by TRICARE in the Information section of this chapter.

Information:

TRICARE is health care program for active-duty service members and retirees of the seven uniformed services, their family members, survivors, and others who are registered in the Defense Enrollment Eligibility Reporting System (DEERS).

TRICARE benefits information is available at: https://tricare.mil/CoveredServices and details about nutrition therapy at: https://manuals.health.mil/pages/ManualsByDate.aspx.

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| Page 14 REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods REQUIRED GUIDANCE: Complete the WIC/Medicaid Nutrition Form

Staff must complete the WIC/Medicaid Nutrition Form (or another form of written documentation) when formulas and/or nutrition products are needed from Medicaid.

Staff must complete the form when participants or caregivers, non-WIC families, hospitals, enteral care providers, or durable medical equipment providers request the form.

Note: Any staff (e.g., clerk, certifier, nutritionist, and coordinator) can complete the WIC/Medicaid Nutrition Form required by Medicaid.

PROCEDURE:

Staff:

A. Complete the WIC/Medicaid Nutrition Form with the following information:

Note: Staff can print the WIC/Medicaid Nutrition Form from the Washington WIC web site: https://doh.wa.gov/you-and-your-family/wic/wic-foods/wic-infant-formula

1. Participant’s name.

2. Caregiver’s name, if participant is an infant or child.

3. The clinic’s contact information including name of clinic, address, and phone.

4. Signature of WIC staff person completing the form.

5. Documentation of one the following three criteria:

a. The participant isn’t eligible for the Washington WIC Program (WIC Program).

b. The participant needs a formula and/or nutrition product (enteral nutrition products) not approved by the WIC Program.

Note: If the requested formula is a WIC formula the participant or caregiver is required to apply for WIC benefits.

c. The participant is eligible for the WIC Program and the formula and/or nutrition product is WIC approved, but the participant needs more than the amount WIC allows. When this applies, document:

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1) The name of the formula and/or nutrition product prescribed.

2) Number of cans requested.

3) Maximum number of cans allowed by WIC.

4) Number of cans requested that WIC can’t provide.

Note: Staff can only provide up to the maximum amount of WIC formula that the WIC Program allows. Medicaid only provides the amount of formula and/or nutrition product in excess to what the WIC Program allows.

B. In the Attach Medical Documentation section of the Food Prescription screen, scan the completed WIC/Medicaid Nutrition Form into Cascades using the Scan Document button.

C. Give the original copy of the WIC/Medicaid Nutrition Form to the participant or caregiver.

1. If the participant or caregiver requests it, staff have the option to mail, fax, or email the WIC/Medicaid Nutrition Form to the participant’s health care provider, Registered Dietitian Nutritionist, , pharmacy, or durable medical equipment provider.

Note: For more information regarding this process, see the “Process to Request Formula from Medicaid” document.

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| Page 16 REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods REQUIRED GUIDANCE: WIC Benefits Provided to WIC Participants Receiving Formulas and/or Nutrition Products from Medicaid, TRICARE, Private Health Insurance or Other Providers

When a WIC eligible participant receives a therapeutic formula and/or nutrition product from Medicaid, TRICARE, private health insurance, or other providers, staff must encourage the participant or caregiver to participate in the WIC Nutrition Program.

WIC participants who receive therapeutic formulas and/or nutrition products from Medicaid, TRICARE, private health insurance, or another provider must be eligible to receive foods in the standard food prescription as appropriate to the participant’s category.

PROCEDURE:

Staff:

A. Inform the participant or caregiver that the participant is eligible to receive WIC approved foods or formula (as appropriate), a health assessment, nutrition education, breastfeeding support, and referrals to other health and social services even if the participant receives a formula and/or nutrition product from Medicaid, TRICARE, or another private health insurance provider.

B. Document in Family Alerts in Cascades the participant’s status of obtaining a formula and/or nutrition product provided by Medicaid, TRICARE, private health insurance, or other providers of formula.

C. Assign a food prescription as appropriate to the participant’s category and nutritional needs.

D. Issue benefits as per WIC policies and procedures.

E. Refer participant to other agencies and organizations to request additional assistance as appropriate and necessary.

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REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods | Page 17 REQUIRED GUIDANCE: Provide Medical Foods and Medical Formulas through WIC

1. When the WIC participant’s health care provider has:

a. Prescribed a formula and/or nutrition product that isn’t on the Washington State WIC Approved Formulas list and

b. The participant isn’t eligible to receive it from Medicaid, TRICARE, or from another health insurance provider, the participant may be eligible to receive it from the Washington WIC Program.

This policy applies to all WIC participants.

2. Clinic staff must contact state WIC staff and provide the following information to request medical food and/or medical formula not included in the Washington State WIC Approved Formulas list:

a. Written documentation from Medicaid, TRICARE, and/or the participant’s own health insurance provider explaining the reason(s) why they won’t provide the prescribed therapeutic formula and/or nutrition product.

1) If Medicaid determined that the medical food and/or medical formula wasn’t medically necessary and denied it for that reason, state WIC staff must consider Medicaid’s evaluation when deciding whether the Washington State WIC Nutrition Program provides the medical food and/or medical formula as prescribed.

b. A completed copy of the Medical Foods and Medical Formulas form from a health care provider.

Note: The Medical Foods and Medical Formulas form can be copied or printed from the Washington State WIC Nutrition Program Web site: https://doh.wa.gov/you-and-your-family/wic/wic-foods/wic-infant- formula

c. WIC staff complete the “Return completed form to your patient or to the local WIC clinic” box on the Medical Foods and Medical Formulas form before giving the form to the participant or caregiver to take to the health care provider. This informs the health care provider where to return the Medical Foods and Medical Formulas form and how to contact local clinic WIC staff if the health care provider has any questions or concerns.

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| Page 18 REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods 3. Once state WIC staff determine the participant is eligible to receive the medical foods and/or formulas from WIC, state staff arrange for the shipment of the approved medical foods and/or formula to the local WIC clinic where the participant gets WIC services.

4. Clinic staff must submit a new Medical Foods and Medical Formulas form to state WIC staff when the previous form expires. State staff must approve the new form for the participant to continue receiving the medical food and/or formula.

5. In addition to prescribed medical foods and medical formulas, WIC participants are eligible to receive a standard food prescription (depending on the participant’s category) when a health care provider has also completed a WIC Medical Documentation Form (MDF) for the appropriate participant category.

a. Clinic staff must follow the same requirements for providing prescribed foods to a participant with an MDF. Refer to the appropriate policies for “General Requirements for Providing Therapeutic WIC Formulas and Foods,” “Deferral to the Registered Dietitian Nutritionist for WIC Foods,” and “Providing Therapeutic WIC Formulas and Foods” for the participant’s category.

Example: A health care provider prescribes Pregestimil for a WIC infant. Pregestimil isn’t on the list of Washington State WIC Approved Formulas. If the participant isn’t able or eligible to receive the formula from Medicaid or from another insurance provider, state WIC staff approves Pregestimil through the medical foods and medical formulas process. If the infant is 6 to 12 months of age, the infant is also entitled to receive appropriate prescribed WIC baby foods if prescribed by the infant’s health care provider.

PROCEDURE:

Staff:

A. Provide the following information to state WIC staff:

1. Participant’s name.

2. Participant’s date of birth.

3. Caregiver’s name, if participant is an infant or child.

4. Participant or caregiver’s phone number.

5. Name and phone number of local WIC clinic staff making the request.

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6. Name and phone number of the WIC Registered Dietitian Nutritionist (RDN) who is knowledgeable about the participant’s condition and medical necessity for the medical food and/or medical formula (recommended).

Note: The Registered Dietitian Nutritionist (RDN) must be the primary contact when requesting therapeutic formula or WENs from State WIC.

7. The date the participant or caregiver would like to receive the first month’s shipment and dates for subsequent monthly shipments.

• A shipping schedule is established to help assure that the medical food and/or formula is delivered to the WIC clinic on a day the staff are available to accept deliveries.

Note: Once state WIC staff approve the medical food and/or formula the participant can expect to receive the product within 2 - 3 weeks.

8. The physical address of the WIC clinic. This is where state staff will send the medical food and/or formula.

Note: Shipping companies require a physical address for delivery and can’t accept a Post Office Box (P.O. Box) number as a delivery location.

B. Submit to state WIC staff a copy of the written documentation from Medicaid, TRICARE, and/or the participant’s health insurance provider explaining the reason(s) why they won’t provide the prescribed medical food and/or formula.

C. Submit to state WIC staff (using a secure email) a completed copy of the Medical Foods and Medical Formulas form from the health care provider documenting the following:

1. Participant’s Name, Date of Birth, and Caregiver name (if applicable).

2. Qualifying Medical Diagnosis warranting the issuance of each medical food and/or medical formula prescribed. The qualifying medical diagnosis must correspond with the medical need of each medical food and/or medical formula prescribed. A symptom description such as “colic”, “constipation”, “rash”, “spitting up”, “vomiting”, or “fussiness” isn’t an acceptable medical diagnosis for WIC.

3. Brand Name of each medical food and/or formula prescribed. Specify the brand name, as well as the company which manufactures the product if known. Because many of these products are developed specifically for a particular

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| Page 20 REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods medical condition, state WIC staff must research the requested product for can/prescription size, reconstitution rates, purpose/use of the product, etc.

4. Amount Needed - Ounces per Day of each medical food and/or formula prescribed. Federal regulations define the maximum amount of the medical food and formula allowed per month.

5. Physical Form. Specify the physical form (e.g., powder, liquid concentrate, ready- to-feed, solid bar, pudding, etc.) of each medical food and/or formula prescribed, and any other descriptive information as appropriate and necessary.

6. Number of months each prescribed medical food and/or formula is required. The length of time must not exceed twelve (12) months for each authorization.

7. Signature of the health care provider.

8. Phone number for the requesting health care provider.

9. Fax number for the requesting health care provider (recommended).

10. Email address for the requesting health care provider (recommended).

11. Date of the request for the medical food and/or formula.

Note: Original, faxed, or electronic forms are acceptable.

D. Before submitting to state WIC staff, in the Attach Medical Documentation section of the Food Prescription screen, scan the completed Medical Foods and Medical Formulas form into Cascades using the Scan Document button.

E. Receive response from state WIC staff whether the participant is eligible to receive the prescribed medical food and/or formula. If eligible, state staff will confirm the brand name, physical form, and amount the participant will receive.

1. The total amount of medical food and/or medical formula provided to each participant per month cannot exceed the maximum amount allowed by USDA/FNS. State WIC staff evaluates: • The medical necessity of the medical food and/or formula requested, and • Whether USDA/FNS and the Washington State WIC Nutrition Program approve the medical food and/or formula requested.

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REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods | Page 21 2. WIC participants only receiving medical foods and/or formulas don’t receive WIC benefits generated through Cascades. State staff enter the medical foods and/or formulas prescription information into Cascades. The participant counts as “participating” as long as the participant has a valid certification period, and the medical foods and formulas prescription is current.

F. Receive information from state WIC staff confirming the expected date of the first and subsequent month’s delivery of the medical food and/or formula.

G. Confirm with the participant or caregiver the brand name, amounts, and delivery dates of the medical foods and/or formula the participant will receive and provide any additional feeding instructions as appropriate.

H. Confirm that the packing slip information, the items shipped, and the original order agree.

1. If the order is correct and complete:

a. Write “complete” and sign and date the packing slip.

b. Make a copy of the packing slip after signing and dating it.

c. Keep the copy and send the original to the state WIC office within 3 days of receiving the shipment.

2. If the order is incomplete or incorrect:

a. Write on the packing slip which items were incomplete or incorrect and describe what was wrong.

b. Contact state WIC office staff for guidance about what to do next.

Note: We use this information to correct the order and to determine whether we should pay for the medical food and/or formula.

I. Have the participant/caregiver sign a document to confirm the participant/caregiver received the product and keep on file for 4 years.

J. Inform the participant or caregiver to contact local WIC clinic staff as soon as possible if the participant transfers to another Washington State WIC clinic and wants to continue or discontinue receiving medical foods and/or formula.

Volume 1, Chapter 24

| Page 22 REQUIRED GUIDANCE: Medical Documentation for Formulas and Foods K. In the Attach Medical Documentation section of the Food Prescription screen, scan the following documents received:

1. Medical Foods and Medical Formulas form from the health care provider.

2. Written documentation from Medicaid, TRICARE and/or the participant’s health insurance provider explaining the reason(s) why they won’t provide the prescribed medical food and/or formula.

L. Issue benefits for prescribed therapeutic WIC formula and/or foods if all the requirements in appropriate policies for “General Requirements for Providing Therapeutic WIC Formulas and Foods,” “Deferral to the Registered Dietitian Nutritionist for WIC Foods” and “Providing Therapeutic WIC Formulas and Foods” appropriate for the participant’s category (e.g., infants, children or women) are met.

M. Make a note in the Individual Care Plan, indicating participant is receiving nutrition from medical foods or formulas provided by State office.

Best Practice: WIC clinic staff complete the “Return completed form to your patient or to the local WIC clinic” box on the Medical Foods and Medical Formulas form when staff give the form to the participant or caregiver to take to the health care provider. This information informs the health care provider where to return the Medical Foods and Medical Formulas form and how to contact local clinic WIC staff if the health care provider has any questions or concerns.