MedicaidPrior AuthMedium impact
mab2025091901
Pennsylvania Medicaid (DHS)·PA · Family Medicine, Internal Medicine, Gastroenterology +3 more·Provider Bulletin
Effective date
Sep 19, 2025
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid now requires prior authorization for all oral enteral nutrition products for beneficiaries age 21 and older, and all pediatric enteral nutrition formulas regardless of administration route for adults. Specific medical necessity criteria including qualifying diagnoses, evidence of malnutrition, and detailed documentation requirements must be met.
Action Required
Immediately: Update prior authorization workflows for enteral nutrition prescriptions for Pennsylvania Medicaid beneficiaries age 21+. Staff must obtain prior auth before prescribing oral enteral nutrition or pediatric formulas for adults. Ensure documentation includes height/weight from past 6 months, current diet, malnutrition evidence, lab reports (albumin, prealbumin, CBC), nutritionist evaluations if available, caloric needs estimate, and attempted dietary modifications. Claims will require reimbursement authorization through PROMISe system.