Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Reminder: Enteral formula prior authorization is based on the number of units of a specific formula provided to a client. A unit is defined as 100 calories of formula.
When a provider submits a prior authorization request for formula, the request should include the number of units per month that are prescribed for the client, not the number of cans or cases provided.
If the provider lists cans instead of units or does not specifically indicate the number of units in the prior authorization request, the request will be classified as pending until the quantity identifier is clarified, resulting in a delay in authorization approval.
Enteral formula units should be listed in the quantity section of the Home Health Services (Title XIX) Durable Medical Equipment (DME)/Medical Supplies Physician Order Form or the Comprehensive Care Program (CCP) Prior Authorization Request Form.
- 1 unit of formula = 100 calories; 1 can of formula has 240 calories
- 240 divided by 100 = 2.4 units per can; M.D. orders 3 cans per day
- 2.4 multiplied by 3 = 7.2 units per day; 7.2 multiplied by 31 = 223.2 units/month (round up)
In this example, the provider will document and submit the request for 224 units on the Home Health Services (Title XIX) DME/Medical Supplies Physician Order Form. The provider should include the number of units in the Qty.* column.
On the CCP form, the provider should include the number of units in the Quantity*/Frequency* field, located in Section E.
For more information, call the TMHP Contact Center at 800-925-9126.