Get Medicaid Enteral Formula Prior Authorization

Filling out the Medicaid Enteral Formula Prior Authorization is an essential process for ensuring that patients receive the necessary enteral nutrition. This guide provides detailed instructions for completing the form online, making the process straightforward for users with various levels of experience.

Follow the steps to complete the authorization form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the recipient's Client ID number, which consists of 2 alphabetic characters followed by 5 numeric characters and another alphabetic character.
3. Provide the recipient's date of birth in the format MM/DD/YYYY.
4. Input the prescriber’s telephone number where they can be reached.
5. Select the mode of administration by choosing either '1' for tube or '2' for oral.
6. Enter the ICD-9 diagnosis code that relates to the medical need for the formula.
7. If the recipient is under one year of age, indicate whether they require a nonstandard infant formula not provided by WIC by selecting '1' for yes or '2' for no.
8. Specify if more than one enteral formula is being prescribed by selecting '1' for yes or '2' for no.
9. Indicate the number of enteral formula calories prescribed per day.
10. Fill in the number of refills requested, up to a maximum of 5.
11. If applicable, respond to question 9a regarding inborn metabolic diseases and question 9b regarding infant formula prescriptions.
12. Provide the patient’s height in inches.
13. Fill in the patient's weight in pounds.
14. For patients under 21 receiving oral administration, answer questions regarding their ability to consume normal foods and whether alternatives have been tried.
15. Note if the patient has experienced significant unintentional weight loss or lack of weight gain and provide details if applicable.
16. Confirm if there is objective medical evidence documenting the need for enteral nutrition.
17. Record the 11-digit prior authorization number for your records and on the patient's enteral formula order or prescription.
18. Save your changes, download, print, or share the completed form as necessary.

Complete your Medicaid Enteral Formula Prior Authorization online today to ensure timely access to necessary nutrition.