Prior Authorization : General Information

Prescription or Order Required for Enteral Nutrition Formula

A copy of the prescription or order that is not greater than one year old is required with each PA request for enteral nutrition formula. Copies may be uploaded with PA requests submitted on the ForwardHealth Portal or attached separately to paper PA requests. Providers are encouraged to submit requests on the Portal in order to receive real-time adjudication.

The following must be indicated on prescriptions or orders for enteral nutrition formula:

• Member name
• Prescription or order date
• Enteral nutrition formula(s) prescribed or ordered
• Calories or milliliters per day (as described in the HCPCS code) prescribed or ordered
• Route of administration
• Length of treatment
• Prescriber's name, signature, and professional credentials