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May 29 2025 Reminder for DME Providers Who Supply Enteral Formula

May 29, 2025: Reminder for DME Providers Who Supply Enteral Formula:  As of July 1, 2024, the Program Review Division no longer accepts verbal authorizations for enteral formulas/supplies via the PACER telephone line (844-PACERMI/844-722-3764). The medical supplier is to submit a prior authorization (MSA 1653-B – Special Services Prior Approval Form) through the Community Health Automated Medicaid Processing System (CHAMPS) or via fax at 517-335-0075.


Include the following:

  • BPHASA-2401: Medical Justification for Enteral Therapy Form*
  • Physician Order
  • Other Supporting Documentation

*BPHASA-2401 Requirements:

  • Ordering practitioners and/or designated clinical staff can complete the BPHASA-2401
  • If a Medical supplier chooses to help complete the BPHASA-2401, they can only complete the Beneficiary ID, Beneficiary First and Last name, Date of Birth, type of enteral formula therapy requested, and formula requested.
  • The ordering practitioner is the only provider allowed to sign the BPHASA-2401 form. If anyone else signs the form, the request will be returned with a denied status, and a notice will be sent to the medical supplier's correspondence address on file in CHAMPS.

Need help submitting a PA through CHAMPS?

Follow the CHAMPS Prior Authorization resource for step-by-step instructions.

 Resources

  • MMP 24-16
  • BPHASA – 2421 Medical Justification for Enteral Therapy WORD XXXX | PDF XXX
    • If BPHASA-2421 is faxed, the form must be submitted with a completed MSA-1653-B, including all requested enteral therapy procedure codes. WORD XXXX | PDF XXX - with instructions