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Washington HCA 13-961 Oral Enteral Nutrition Order

Washington Apple Health uses this prescription and order form for oral enteral nutrition products. The prescriber lists each product by HCPCS code with calories per unit, daily quantity, monthly calories and the HCPCS units that result, along with directions for use. The form stays in the client file, and the supplier sends it for review when the Apple Health billing guide requires it.

Who completes it

The prescribing practitioner completes and signs it, working with a registered dietitian to set the calories prescribed. For thickeners ordered for infants under one, the parent or guardian, prescriber, PCP, speech-language pathologist and dietitian acknowledge a safety warning.

Submitting and payment

How to submit it
Give the signed order to the supplier, which keeps it in the client file and submits it, with the HCA 13-835 cover form, when prior authorization is needed under the billing guide.

Good to know

  • Enteral products are reimbursed by HCPCS units, so the prescriber and dietitian must state the calories prescribed for units to be calculated correctly.
  • Signature and date stamps are not accepted on the prescriber attestation, which certifies the medical necessity information is true, accurate and complete.
  • For infants under one year, a thickener attestation reflects FDA and American Academy of Pediatrics warnings about products like Simply Thick and the risk of necrotizing enterocolitis.
  • Related forms include the HCA 13-109 Oral Enteral Nutrition Assessment dietitian worksheet, PA request forms 13-110 and 13-111, and the EPA worksheets.

Get the official form

Download the current version from the source each time; forms change without notice.

Enteral Nutrition Products Prescription Form (Oral Enteral Nutrition)

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How this list is checked

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Frequently asked questions

Why does the Washington enteral nutrition order ask for calories?

Apple Health reimburses enteral products by HCPCS units. The form asks for calories per product, quantity per day, calories per day and per month, and the resulting HCPCS units per month. The prescriber and registered dietitian must identify the calories prescribed so the units can be calculated accurately.

Is HCA 13-961 sent to HCA every time?

Not always. The form is kept in the client file, and the Apple Health billing guide determines when it must be submitted for review. When prior authorization is required, it is sent with the authorization paperwork, such as the HCA 13-835 cover form.