NYS Medicaid Enteral Formula Prior Authorization

To submit the NYS Medicaid Enteral Formula Prior Authorization form, ensure all fields are accurately completed. Submit the form via mail to OHIP Medical Prior Approval, 150 Broadway, Albany, NY 12204. Alternatively, contact the Division of OHIP Operations, Bureau of Medical Prior Approval at 1(800) 342-3005, option 1, for further instructions.

There are no specific important dates for submitting this form in 2024 and 2025, but timely submission is crucial. Ensure to check for any updates or changes in guidelines from NYS Medicaid.

The purpose of the NYS Medicaid Enteral Formula Prior Authorization form is to obtain necessary approval for prescribing enteral formulas to Medicaid patients. This form ensures that patients receive the appropriate nutritional support based on their medical conditions. By accurately completing and submitting this form, prescribers can help facilitate the authorization process and provide timely care to their patients.

• 1. Prescriber type: Select the appropriate type of prescriber from the provided options.
• 2. Transaction type: Select the transaction type, whether it is a new request, cancellation, or inquiry.
• 3. Prescriber's National Provider ID (NPI) #: Enter the 10-digit NPI number of the prescriber.
• 4. Beneficiary CIN: Provide the Client ID number, which consists of 2 alpha, 5 numeric, and 1 alpha character.
• 5. Beneficiary Date of Birth: Enter the date of birth in MM/DD/YYYY format.
• 6. Prescriber telephone number: Provide a contact number where the prescriber can be reached.
• 7. Mode of administration: Indicate whether the formula is administered orally or through a tube.
• 8. Enteral formula for Inborn Metabolic Disease: Specify if the formula is for an inborn metabolic disease and provide the ICD-9 code.
• 9. Enteral formula for infant condition: Answer if the formula is for an infant with lactose intolerance or severe food allergy.
• 10. More than one enteral formula: Indicate if more than one enteral formula is being prescribed.
• 11. Number of enteral formula calories prescribed per day: Specify the daily calorie intake prescribed.
• 12. Number of refills: Provide the number of refills required.
• 13. Patient height in inches: Enter the patient’s height in inches.
• 14. Patient weight in pounds: Enter the patient’s weight in pounds.
• 15. Medical condition preventing food consumption: Answer if the patient has a condition preventing consumption of normal foods.
• 16. Unintentional weight loss: Specify if the patient experienced significant unintentional weight loss over the past two months.
• 17. Objective medical evidence: Provide evidence supporting the need for enteral nutrition, such as serum protein levels or hemoglobin levels.

Failure to submit this form may result in delays or lack of authorization for the necessary enteral formula. It is essential to provide accurate and complete information to avoid any issues.

• Delay in Authorization: Failure to submit the form may cause delays in obtaining authorization for enteral nutrition.
• Lack of Nutritional Support: Patients may not receive the required enteral formula, impacting their nutritional intake.
• Denied Claims: Incomplete or inaccurate submissions can result in denied claims by Medicaid.

• 1. Prescribing Enteral Formulas: When a prescriber needs to obtain authorization for enteral nutrition.
• 2. Medical Conditions Requiring Enteral Nutrition: For patients with conditions that necessitate enteral formulas.
• 3. Supplemental Nutrition for Low BMI: For adults and children with a BMI less than 18.5 needing supplemental nutrition.
• 4. Inborn Metabolic Diseases: For patients diagnosed with inborn metabolic diseases requiring enteral support.
• 5. Infant Conditions: For prescribing specialized formulas for infants with specific medical conditions.