Reset Form Ohio Department of Medicaid CERTIFICATE OF MEDICAL NECESSITY/ PRESCRIPTION ENTERAL NUTRITION SERVICES Medicaid Supplier/Pharmacy Provider Name SECTION A INITIAL Provider NPI and Medicaid.
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How to fill out the Saxyopan online
The Saxyopan is an essential document required for enteral nutrition services. This guide provides clear, step-by-step instructions on how to complete the form accurately and efficiently.
Follow the steps to complete the Saxyopan form successfully.
- Press the ‘Get Form’ button to access the Saxyopan form and open it in your document editor.
- In Section A, fill out the provider NPI and Medicaid legacy number, certification type, and the prescription date. Indicate if there is a change in the prescriber order and provide the previous authorization (PA) number if applicable.
- Next, enter the consumer's name and date of birth. Specify if the recipient is receiving nutritional supplements from the WIC program by selecting 'Yes' or 'No'. If 'Yes', note the product(s) and amount supplied.
- In Section B, the prescriber must complete the certification. Start by entering the diagnosis codes and descriptions. Confirm if the consumer has any absorption issues or requires tube feeding and explain if applicable.
- If there are no absorption problems, provide reasons why enteral nutrition is required and include relevant lab values if necessary. Document the consumer's weight history if they cannot maintain weight on regular food.
- Include lab results that indicate any nutritional deficiencies if applicable. Specify the length of need in months, which cannot exceed a maximum approval period of 12 months.
- Detail the prescribed enteral product and its calorie requirements. If daily calorie requirements exceed 2000, provide an explanation.
- Complete the section on enteral administration supplies if tube feedings are necessary. Document the number of calories per can, daily calorie intake, and the number of cans per case.
- The prescriber must print their name, sign the form (no stamps allowed), and provide their NPI and Medicaid legacy number, contact number, and date.
- After filling in all required fields, save your changes, and select the option to download, print, or share the completed Saxyopan document.
Complete your Saxyopan form online today for efficient processing.
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