How to Fill Out the New York Medicaid Enteral Formula Prior Authorization

To get New York Medicaid enteral formula prior authorization, the prescribing provider submits the request through the online Enteral Portal at MEDICAIDENTERALPORTAL.health.ny.gov or by calling the Interactive Voice Response line at 1-866-211-1736. If the clinical answers meet the automated criteria, the system issues a PA number on the spot, and the prescriber passes that number to the dispensing pharmacy or DME supplier.¹ There is no single paper form to mail for most requests.

Rules changed on February 11, 2026. Daily calorie ceilings went up, refill allowances expanded for certain patients, and new monthly unit caps took effect under 18 NYCRR § 505.5.²

What to Have Ready Before You Start

The prescriber must be an enrolled New York Medicaid provider.¹ A Prescriber Worksheet is published as a preparation guide; the worksheet itself is never submitted, but it mirrors every question the portal and IVR will ask, so filling it out first prevents a dropped call or a timed-out session.

Gather the following before logging in or dialing:

Your National Provider Identifier.
The patient’s Medicaid Client Identification Number, formatted as two letters, five numbers, and one letter, plus the patient’s date of birth.
Mode of administration: tube or oral.
The patient’s current height in inches and weight in pounds, which the system uses to calculate BMI for oral-fed requests.
The ICD-10 diagnosis code, if the formula is for an inborn metabolic disease.
The number of formulas prescribed, total calories per day, and number of refills requested.

For oral-fed patients with a BMI under 18.5, the medical record must support yes-or-no answers to the clinical screening questions. The portal will ask whether a medical condition prevents the patient from eating normal table food (including softened, mashed, pureed, or blenderized alternatives); whether less intensive options such as dietary changes, instant breakfast drinks, or rice cereal were tried and failed; whether the adult has unintentionally lost more than five percent of body weight in the past two months (or, for children, failed to gain weight in the past six months); and whether objective medical evidence exists, such as abnormal serum protein, albumin, or hemoglobin levels, visible skin or bone changes, or physiological complications from surgery.³ A “no” to any of these will stop the automated approval.

Setting Up Portal Access

First-time users create an account at MEDICAIDENTERALPORTAL.health.ny.gov with their NPI, name, email address, and a mobile number for two-factor verification. The password must be at least 14 characters and include a letter, a number, and a special character.⁴ Prescribers who prefer phone-based entry can give the same information verbally through the IVR line at 1-866-211-1736.⁵

Entering the Request Step by Step

Once logged in, the prescriber works through the following prompts in order:⁴

Select transaction type: a new request, a cancellation of an existing authorization, or an inquiry on an existing PA number.
Enter the member’s CIN and date of birth.
Select mode of administration (tube or oral).
If the formula treats an inborn metabolic disease, enter the ICD-10 code.
Enter the number of formulas, total calories per day, and refills requested. Adults with a BMI under 18.5 can receive up to five refills on a single authorization.
For oral-fed patients without an inborn metabolic diagnosis, enter height and weight, then answer the clinical screening questions.

If the entries meet the automated criteria, the system issues a PA number immediately. Give that number to the dispensing pharmacy or DME supplier, who needs it to submit a clean claim.

Calorie Limits the Automated Systems Will Approve

Automated approval through the portal or IVR is bounded by daily calorie limits and monthly unit caps.²

Tube-fed patients: up to 2,500 calories per day (raised from 2,000 in February 2026), with a monthly maximum of 750 caloric units.
Oral-fed patients with a BMI under 18.5: up to 1,250 calories per day, with a monthly maximum of 375 caloric units.
Oral-fed adults with a BMI between 18.5 and 24.9 who were previously approved for supplemental nutrition can continue coverage, but through paper prior approval rather than the portal.

Standard milk-based infant formulas, formulas used as a food substitute for convenience, and oral-fed adult requests above the supplemental cap are not covered benefits at all.⁶

When You Must Use Paper Prior Approval Instead

Several situations fall outside the portal and have to be submitted on paper through ePACES or by fax:³

Tube feeding or inborn metabolic disorders requiring more than 2,500 calories per day.
Children under 21 who need more than 1,250 calories per day or whose BMI is 18.5 or above.
Oral-fed adults with a BMI between 18.5 and 21.9 requesting supplemental nutrition up to 1,000 calories per day, supported by documented unintentional weight loss of at least five percent over six months.
An oral-fed adult with a BMI under 18.5 needing a third authorization in any 365-day period.
Adults whose anatomy permanently prevents normal eating; the 1,000-calorie supplemental cap does not apply to these patients.
A pharmacy or vendor change when the current pharmacy closes or the patient can no longer reasonably access it and refills remain on the authorization.

Paper prior approval is not available for oral-fed adults requesting supplemental nutrition above 1,000 calories per day, nor for patients who simply want to switch pharmacies when the current one can still fill the order.³ Pediatric requests outside the automated limits are often supportable under the federal EPSDT mandate when the prescriber submits thorough documentation on paper — growth charts, lab values, and a clear statement of medical necessity.⁷

Handing Off to the Dispenser

Once the prescriber has a PA number, the dispensing pharmacy or DME company logs into the same Enteral Authorization portal and enters the PA number, the member’s CIN, and the four-digit enteral product code (the HCPCS code without the leading “B”).⁴ The system displays the authorized amount so the dispenser can verify before delivery and billing through eMedNY.

If the formula changes and the authorization needs to be cancelled, either the prescriber or dispenser can cancel through the portal as long as the PA has not already been billed. A PA that has been rendered or billed cannot be cancelled online; a cancellation request form must be faxed to 518-474-4413.⁴ After cancellation, a new automated authorization can be obtained through the portal or IVR.²

How Long It Takes and What to Do If the Patient Needs Formula Now

Automated requests that meet the criteria are approved immediately with no review period. Paper prior approvals routed through ePACES go to a human reviewer. For managed care enrollees, New York requires a standard prior authorization decision within three business days after all information is received, and no longer than 14 calendar days total. An extension of up to 14 additional days is permitted in certain circumstances. Expedited requests for urgent medical needs must be decided within 72 hours.⁸

When a patient needs formula urgently and no PA number has been issued, New York Medicaid allows the pharmacy to dispense a 72-hour emergency supply under the NYRx Pharmacy Provider Manual.⁹ The pharmacist must judge that withholding the formula could harm the patient and should make a good-faith effort to reach the prescriber first. The override is for genuine emergencies, not routine delays.

If the Request Is Denied

Read the denial notice first. Many denials come down to incomplete clinical documentation rather than a true coverage dispute, and resubmitting a new authorization with the missing records (lab values, weight history, evidence that dietary alternatives failed) is faster than appealing.

Beneficiaries also have the right to request a fair hearing through the Office of Temporary and Disability Assistance under 42 CFR Part 431, Subpart E.¹⁰ For fee-for-service Medicaid, which covers most enteral formula requests, the beneficiary has 60 days from the date of the denial notice to request a hearing. Managed care enrollees who have exhausted the plan-level appeal have 120 days. Hearings can be requested by calling 800-342-3334 or through otda.ny.gov/hearings/request.

1
eMedNY. New York State Medicaid Program – Enteral Formula Prior Authorization Prescriber Worksheet
2
eMedNY. New York State Medicaid Program – Enteral Nutrition Regulatory Amendment and Prior Authorization Changes
3
eMedNY. Enteral Formula Prior Authorization Prescriber Worksheet Instructions
4
eMedNY. New York State Medicaid Enteral Prior Authorization Portal Instructions
5
eMedNY. New York State Medicaid Program Enteral Formula Prior Authorization Dispenser Worksheet
6
New York State Medicaid. New York State Medicaid Enteral Prior Authorization – Prescribers, Durable Medical Equipment Providers, and Pharmacies
7
Medicaid.gov. EPSDT – A Guide for States
8
New York State Department of Health. New York State Medicaid Managed Care Service Authorization and Appeals Timeframe Comparison
9
New York State Department of Health. Transition of the Pharmacy Benefit from Managed Care to Fee-for-Service – FAQ
10
eCFR. Fair Hearings for Applicants and Beneficiaries