Wisconsin Medicaid requires this four-page attachment when enteral nutrition formula needs prior authorization. It captures caloric requirements, how formula is given, diagnoses, height and weight, and why table foods or general-purpose formula are not enough. Section VII converts calories or milliliters into units requested, and the billing provider signs before the request goes to ForwardHealth with the PA/RF.
Clinical content comes from the prescriber, often with a dietitian, and the prescriber's name and NPI appear in Section II. Section IX is signed by the billing provider, who certifies that clinical information submitted with the request was obtained from the prescriber.
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Prior Authorization/Enteral Nutrition Formula Attachment (PA/ENFA)
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Section IX carries the authorized signature of the billing provider, with printed name, position title and date. By signing, the billing provider attests to the accuracy and completeness of the request and that clinical information submitted with it, such as medical records, was obtained from the prescriber.
Element 15 lists inborn errors of metabolism, conditions requiring specialized oral nutrition such as a ketogenic diet or eosinophilic esophagitis, impaired absorption, central nervous system disease interfering with ingestion, nutritional deficiency, chronic disease such as end-stage renal disease, ongoing cancer treatment, and other.
Section III asks for the date the prescription or order was written and says it should not be more than one year old. A copy must be submitted with each PA request, and Element 16 asks for any clinical changes since previously approved requests.