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May 29 2025 Reminder for DME Providers Who Supply Enteral Formula
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.
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