Michigan Medicaid requires the BPHASA-2401 to justify enteral formula, thickener or Relizorb for a beneficiary. The ordering practitioner documents the diagnosis and history behind the need, current height, weight and BMI, the weight trend, other coverage, and for up to three products the route, diet, daily caloric requirement and calories from formula, plus less costly alternatives already tried.
The ordering practitioner or designated clinical staff, such as a dietitian or registered nurse, completes all clinical fields, and the practitioner signs with specialty. The DME supplier may enter only the beneficiary ID, name, date of birth, therapy type and formula requested.
Download the current version from the source each time; forms change without notice.
Medical Justification for Enteral Therapy
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The ordering practitioner or the practitioner's designated clinical staff, such as a dietitian, registered nurse or other appropriate hospital clinical staff, completes the clinical fields, and the practitioner signs. The DME supplier may complete only the identifying fields, therapy type and formula requested.
Yes. The form has space for up to three enteral products, each with therapy type (formula, thickener or Relizorb), oral or tube route, formula name, diet type, total daily caloric requirement, calories per day from the formula, and the alternatives tried.
Yes. The form states it must be typewritten, so complete the PDF on a computer. If it is faxed, it must go with a completed MSA-1653-B that lists every enteral therapy procedure code being requested.