Get Nys Medicaid Enteral Formula Prior Authorization

Filling out the NYS Medicaid Enteral Formula Prior Authorization form online is a crucial step in ensuring that beneficiaries receive the necessary nutritional support. This guide will provide you with a clear, step-by-step approach to complete the form accurately and efficiently.

Follow the steps to complete the authorization form online.

1. Press the ‘Get Form’ button to access the authorization form in the online system.
2. Identify your prescriber type by selecting one of the available options, such as Physician, Nurse Practitioner, or Dentist.
3. Choose the transaction type by selecting either 'New Request' or 'Cancel an Authorization' as appropriate.
4. Enter the prescriber’s National Provider ID (NPI) number as well as the Client Identification Number (CIN) for the beneficiary.
5. Input the beneficiary’s date of birth formatted as MM/DD/YYYY.
6. Provide a contact number for the prescriber where they can be reached.
7. Select the mode of administration: either 'Tube' or 'Oral'. If 'Tube' is chosen, be prepared to provide the relevant ICD-9 diagnosis code.
8. If 'Oral' is selected, indicate whether the formula is prescribed for an Inborn Metabolic Disease and include the corresponding ICD-9 code.
9. Answer additional questions related to the patient's condition, such as the necessity of the formula for specific medical issues.
10. State whether more than one enteral formula is being prescribed and provide the daily calorie count as well as the number of refills requested.
11. Record the patient's height and weight to assess the necessity of the nutritional formula.
12. Finalize the form by ensuring all required fields are filled, then save your changes, and choose to download, print, or share the completed authorization form.

Start filling out the NYS Medicaid Enteral Formula Prior Authorization online today!