- Participating Physician Groups (PPG)
Enteral nutrition products are a conditional benefit under the Health Net Medi-Cal program. Prior authorization is required. Enteral nutrition products are used as a treatment plan for conditions that do not accept the full use of regular food. This is subject to Medi-Cal's list of enteral nutrition products and utilization controls.
Coverage for enteral nutrition products, including therapeutic infant formula, must meet medical necessity criteria. It cannot be a convenience item or used in place of food for social and economic reasons. If regular foods are available to provide needed nutrients and calories, then enteral nutrition becomes a convenience item, which is not covered.
Benefits for Members Ages 21 and Over
The Department of Health Care Services (DHCS) and Health Net may deem a nutrition product taken by mouth a medically necessary benefit for patients ages 21 and over. This applies to certain diagnoses, such as intestinal malabsorption and inborn errors of metabolism among others. It can also apply to medical conditions where enough nutrition is not achieved with dietary changes or from soft or pureed foods.
Benefits for Members Under Age 21
Members under age 21 are covered by the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program. Enteral nutrition is a covered benefit for California Children's Services (CCS) eligible diagnoses, such as malabsorption, genetic disorders and inborn errors of metabolism. If the member qualifies for coverage under the CCS program, then CCS-approval should be obtained for medically necessary enteral nutrition. Information on therapeutic infant formula is located in the Maternity section.
Prior Authorization Process
Prior authorization is required for enteral nutrition products and supplies. Providers participating through a participating physician group (PPG) should follow the PPG's guidelines for prior authorization.
Fee-for-service (FFS) providers must complete the Inpatient California Medi-Cal Prior Authorization Form (PDF) or the Outpatient California Medi-Cal Prior Authorization Form (PDF) for members over age one. For therapeutic infant formula or banked human milk for infants up to age one, FFS providers must complete the Infant Nutrition Benefits Authorization Request Form: Therapeutic Formula - Health Net (PDF) or Therapeutic Formula - CalViva Health (PDF). Fax completed forms to the Medical Management Department.
The CCS program also requires a Service Authorization Request (SAR) for enteral products for CCS-eligible conditions.
Products billed must be identical to products authorized.
Authorization Time Frames
Decisions regarding enteral nutrition products are performed timely. They are based on the member's medical condition within the following time frames:
|Type of Request||Time Frame|
Emergency requests occur when prescribing providers determine the product is required immediately to prevent serious disability or death. Prior authorization is not required when there is truly an emergency requiring immediate treatment
72 hours of receipt of all the information reasonably necessary to make a decision. Urgent requests occur when the requesting provider or Health Net determines that following the standard time frame could seriously jeopardize the member's life, health or ability to attain, maintain or regain maximum functions
5 business days of receipt of all the information reasonably necessary to make a decision. Routine requests are for treatment plans already in place
If a decision about enteral nutrition products is delayed past these time periods, the request is considered approved.