On September 22, 2023, prior authorization (PA) requirements for members 22 years of age and older will be reinstated for new start enteral nutrition orders. Providers can begin PA submissions for enteral nutrition products on and after September 22, 2023.
“New starts” are defined as new enteral nutrition therapy not previously prescribed to the member during the 15-month lookback period.
Claims will deny for Reject Code 75 as all enteral nutrition product claims require a PA.
Beginning November 9, 2023, the Transition Policy will be retired for all enteral nutrition products for members 22 years of age and older. Retirement of the Transition Policy will reinstate PA requirements for all enteral nutrition products for members 22 years of age and older. As a result, claims that previously paid under the Transition Policy will now require a PA.
You can submit a PA request via one of the approved Medi-Cal Rx submission methods:
- CoverMyMeds®.
- Medi-Cal Rx Secured Provider Portal.
- Fax.
- U.S. Mail.
Before submitting a PA, consider the following checklist:
- Review the List of Contracted Enteral Nutrition Products. Only products on this established Medi-Cal Rx list are covered.
- Verify prescription requirements are met.
- Verify billing requirements and limitations are met.
- Verify that providers are including the following required information to meet the PA documentation requirements when submitting a PA request:
- Medical diagnosis code related to the product requested.
- Height (length), weight and daily caloric requirements.
- Route of administration (orally fed or tube fed).
- 11-digit product NDC.
- Supporting documentation as attachments must be signed by the physician.
For more information, you can also refer to the August 9 notification and the August 16 notification from DHCS.
Questions? Call the Medi-Cal Rx Customer Service Center at 800-977-2273 (available 24/7) or email Medi-Cal Rx Education & Outreach at [email protected].
