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PRIOR AUTHORIZATION / ENTERAL NUTRITION PRODUCTS ATTACHMENT (PA/ENPA)
Page 4 of 4
F-11054 (10/12)
SECTION VI — ADDITIONAL INFORMATION
21. Include any additional information in the space below, including a description of the member’s dietary assessment and dietary
plan.
SECTION VII — PRIOR AUTHORIZATION REQUEST INFORMATION FOR CALORIES PER DAY
25. Calories
26. Number of
27. Units Requested
22. Procedure
23. Modifiers, if
24. Product Trade Name
Per Day
Days
(Element 25 x
Code
Applicable
Requested
Requested
Element 26 / 100)
e.g.
B4150
Ensure
1,000
365
3,650
A.
B.
C.
SECTION VIII — PRIOR AUTHORIZATION REQUEST INFORMATION FOR MILLILITERS PER DAY (For PA requests for
procedure codes B4102* and B4103* only.)
31. Milliliters
32. Number of
33. Units Requested
28. Procedure
29. Modifiers, if
30. Product Trade Name
Per Day
Days
(Element 31 x
Code
Applicable
Requested
Requested
Element 32 / 500)
e.g.
B4103
Pedialyte
1,000
365
730
A.
B.
SECTION IX — AUTHORIZED SIGNATURE OF BILLING PROVIDER
By signing below, I agree to the truthfulness, accuracy, timeliness, and completeness of this PA request and that any clinical
information (i.e., medical records, other documentation) submitted with this request was obtained from the prescriber.
34. SIGNATURE
35. Printed Name
36. Position Title
37. Date Signed
FOR OFFICE USE ONLY
* Providers may refer to the Healthcare Common Procedure Coding System code book for procedure code descriptions.
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