Oral enteral nutrition: exception to rule (ETR) request
Oral Enteral Nutrition
Exception to Rule (ETR) Request
Fax completed form with completed HCA 13-961 Enteral Nutrition Products Prescription Form to: 1-866-668-1214.
All requests must have a typed, completed HCA 13-835 General Information for Authorization form as the coversheet .
|Oral enteral nutrition is not a covered benefit for adults 21 and older. In order to request an ETR, complete the following in its entirety. Please fill out this |
|form only if the client’s nutritional requirements cannot be met by food/products available in the store, including homemade liquid nutritional supplements. (WAC |
|182-501-0160). |
|To be completed by Vendor and Prescribing Provider |
|CLIENT INFORMATION |
|Client name |Client ID |
| | |
|Client residence |
|Private home Adult family home or boarding home (e.g., ALF) Other state-funded living |
|Other, please specify: |
|VENDOR INFORMATION |
|Vendor name and name of contact at vendor’s office |Provider NPI |
| | |
|Vendor telephone number |Fax number |
| | |
|SERVICE REQUEST INFORMATION |
|Nutrition product requested |Quantity in HCPCS units per day |Length of need |HCPCS code |
| | | | |
|Medical diagnosis- ICD-10 code and description |Nutritional diagnosis – ICD-10 code and description |
| | |
|To be completed by prescribing provider |
|Explain why this client is so clinically/medically unique from others with a similar condition (diagnosis) that the department should grant an exception to rule. |
| |
| |
|Medical justification: Does this client have a condition that affects his/her ability to break down, digest, or absorb nutrients? Yes No |
|If “Yes,” what is the condition? |
|What other alternatives/less costly nutrition sources have been tried? What was the outcome of the trials? (Apple Health/Medicaid does not pay for products |
|available at a store or those that could be prepared in the residence by the client or others.) |
|Lab results to support diagnosis (E.G. Albumin, Pre-albumin to indicate malnutrition) – ATTACH RESULTS TO REQUEST |
|Weight |BMI |Date weighed |
| | | |
|Prescribing physician’s name |Telephone number |Provider NPI |
| | | |
HCA 13-864 (6/17)
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