Fillable Mnr Absorbent (Commonwealth of Massachusetts)

Fill Online, Printable, Fillable, Blank Mnr Absorbent (Commonwealth of Massachusetts) Form

Use Fill to complete blank online COMMONWEALTH OF MASSACHUSETTS (MA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Mnr Absorbent (Commonwealth of Massachusetts)

On average this form takes 28 minutes to complete

The Mnr Absorbent (Commonwealth of Massachusetts) form is 3 pages long and contains:

  • 0 signatures
  • 34 check-boxes
  • 98 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Sections 1, 2, 3, and 4 may be completed by the provider of DME or the prescribing provider. Section 5 must be completed by the provider of
DME. Sections 4A, 6, and 7 must be fi lled out by the prescribing provider.
SECTION 1
Member Name
Date of Delivery / /
Address
Telephone No.
City
State Zip
MassHealth ID No.
Date of Birth / / Gender Height Weight
Primary ICD Code
Description
Secondary ICD Code
Description
SECTION 2
Prescribing Provider’s Name
NPI
Address
Telephone No.
Fax No.
SECTION 3
Name of provider of DME
NPI
Address
Telephone No.
Fax No.
SECTION 4 SECTION 4 A
Place checkmark beside item requested and enter the appropriate size, Must be completed by prescribing provider
HCPCS code, and modifi er.
Item Requested Size HCPCS Code Modifi er Daily Units No. of Monthly Refi lls Length of need
1. Diaper:
Reusable Disposable
Adult Child
2. Pull-up/Pull-on:
Reusable Disposable
Adult Child
3. Insert/liner
4. Disposable underpad/bedpad:
5. Reusable underpad/bedpad:
6. Is this a request to exceed the quantity limits for any absorbent product? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
If yes, current prior-authorization (PA) no.: _________________________________________
If yes, documentation must be submitted in accordance with Section 6, Question 11.
7. Is this a request to change the size of absorbent products?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
If yes, current PA no.: ___________________________________
continued on back
MASSHEALTH PRESCRIPTION AND MEDICAL NECESSITY REVIEW FORM
FOR
ABSORBENT PRODUCTS
THE COMMONWEALTH OF MASSACHUSETTS
Executive O ce of Health and Human Services
MNR-AP (11/14)
Print
Reset
SECTION 5
Provider of DME Attestation, Signature, and Date
I certify under the pains and penalties of perjury that the information on this form and any attached statement that I have provided has
been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I also certify that I am the provider or, in
the case of a legal entity, duly authorized to act on behalf of the provider. I understand that I may be subject to civil penalties or criminal
prosecution for any falsification, omission, or concealment of any material contained herein.
Signature of provider of DME (Signature and date stamps, or the signature of anyone other than the provider of DME
or a person legally authorized to sign on behalf of a legal entity, are not acceptable.)
Printed legal name of provider Date / /
Printed legal name of individual signing (if the provider is a legal entity)
SECTION 6
Section 6 must be completed by the member’s prescribing provider or his or her sta. Complete all applicable questions and attach any
pertinent information (i.e., lab tests, medical history and physical examination, clinical notes, etc.). Please check all boxes that apply for
each question.
Answer Questions 1 – 6 for all requests for absorbent products.
1. Member presents:
Stress incontinence
Urge incontinence
Mixed incontinence
Overflow incontinence
Total/functional incontinence
Indeterminable incontinence
Fecal incontinence
Other (specify) ______________________________________________
2. Has a focused medical history and targeted physical exam been
performed to detect factors contributing to incontinence, that, if treated,
could improve or eliminate incontinence? (See
MassHealth Guidelines
for Medical Necessity Determination for Absorbent Products
for specific
contributing factors.). . . . . . . . . . . . . . . . .
Yes No
(If yes, attach medical history and physical exam).
3. Risk factors identified for developing incontinence:
Urological disorder
Impaired cognitive function
Neurological disorder
Impaired mobility
Other (specify) ______________________________________________
4. The following tests/exams have been conducted:
(Please attach results.)
Urinalysis/culture sensitivity
Urological test/consultation
Rectal examination
Pelvic examination (women)
Developmental assessment and prognosis (children)
5. Have treatments (for example, behavioral techniques, pharmacologic
therapy, and/or surgical intervention) to manage symptoms of
incontinence been tried and failed or been
partially successful? . . . . . . . . . . . . . . . . .
Yes No
(If yes, attach clinical evidence of such treatment(s), treatment results,
and member’s responsiveness.)
6. Is it the prescribing provider’s determination that the product is
necessary to manage observable symptoms of incontinence in
circumstances where the member or caregiver (family member
or guardian) refuses to have a medical history taken, physical
exam conducted, and/or treatments accepted for incontinence?
(Documentation that the member or caregiver refused medical history,
examination and/or treatments “against medical advice” must be
provided.) . . . . . . . . . . . . . . . . . . . . . . .
Yes No
Answer Question 7 if requesting pull-up/pull-on absorbent briefs.
7. Does the member have a condition that causes incontinence and is he or she participating in or has participated
in a toilet-training program? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
If it is impractical for the member to participate in a toilet-training program, list reason(s) here:
Does the member have the cognitive and physical ability to pull up and take o briefs on his or her own? . . . . . . . . . . . . . . . . . .
Yes No
Is the member bed-ridden? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
Member Name:
Answer Question 8 if requesting absorbent liners/inserts.
8. Does the member report light or infrequent incontinence?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
Answer Question 9 if requesting any type of absorbent underpads/bedpads.
9. Is the member using absorbent products and does the member report leakage?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
Does the member report leakage when there is an indwelling catheter? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
Is the member able to reposition independently? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
Answer Question 10 if requesting both reusable and disposable underpads/bedpads.
10. Does the member report high volume of urine or fecal leakage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes No
Please provide additional documentation if requesting a number of units that exceed the maximum allowable.
11. Clinical documentation must be submitted to justify the medical need for a quantity of absorbent product that is above the allowable limit set forth
in the
MassHealth DME and Oxygen Payment and Coverage Guidelines Tool
. Refer to
MassHealth Guidelines for Medical Necessity Determination for
Absorbent Products
, Clinical Coverage, Section II.A.12, for criteria justifying a number of units that exceed the maximum allowable.
SECTION 7
Prescribing Provider’s Attestation, Signature, and Date
I certify under the pains and penalties of perjury that I am the prescribing provider identified in Section 2 of this form. Any attached
statement on my letterhead or assessment on this form has been reviewed and signed by me. I certify that the medical necessity information
(per 130 CMR 450.204) on this form is true, accurate and complete, to the best of my knowledge. I understand that I may be subject to civil
penalties or criminal prosecution for any falsification, omission, or concealment of any material contained herein.
Prescribing provider’s signature (Signature and date stamps, or the signature of anyone other than the prescribing provider, are not acceptable.):
Check applicable credentials:
MD NP PA
Printed name of prescribing provider: Date / /
Member Name:
Print
Reset
Instructions for Completing the MassHealth Prescription and Medical Necessity Review Form for
Absorbent Products
Sections 1, 2, 3, and 4 may be completed by the provider of DME or the prescribing provider.
Instructions for the
Use of this Form
Providers of DME are instructed to use this form when obtaining a Prescription and Letter of Medical Necessity
from the member’s prescribing provider for absorbent products, and as an attachment to a prior-authorization (PA)
request for absorbent products. Providers of DME are responsible for ensuring compliance with applicable MassHealth
regulations and guidelines when using this form. MassHealth reserves the right not to accept the form if it is completed
improperly, or if the provider has failed to meet applicable MassHealth regulations, requirements, and guidelines,
including without limitation medical necessity requirements. Please refer to the
MassHealth Guidelines for Medical
Necessity Determination for Absorbent Products
for further information about required clinical documentation and
information that must be submitted for PA requests for absorbent products. A copy of this completed form (including
all attachments and supporting documentation) must be maintained in the member’s medical record at the prescribing
provider’s oce and at the provider of DME’s oce.
Section 1 Enter the date of delivery of the absorbent products at the top of the form. The date of delivery on this form must match
the date on the delivery slip required under 130 CMR 409.419. Enter the member’s name, address (including apartment
number, if applicable), telephone number, MassHealth member ID number, date of birth, gender, height, weight, and
applicable ICD diagnosis code(s) with their descriptions. Once the delivery has been made, enter the date of the delivery
in the date of delivery field in the upper right corner of Section 1.
Section 2 Enter the prescribing provider’s name, NPI number , address, telephone, and fax numbers.
Section 3 Enter the name of provider of DME, NPI number, address, telephone, and fax numbers.
Section 4 Place a checkmark beside the item requested. Enter the size, HCPCS code(s), and modifier(s).
Section 5 The provider of DME must sign and enter the date the form was completed in Section 5. By signing the form, the provider
is making the certifications contained above the signature line. Note: Signature and date stamps, or the signature
of anyone other than the DME provider or a person legally authorized to sign on behalf of a legal entity (if the
provider of DME is a legal entity), are not acceptable.
Sections 4A, 6, and 7 must be completed by the prescribing provider
Section 4A The prescribing provider must enter the total number of monthly units, monthly refills, and expected duration of use of
absorbent products by the member.
Section 6 The member’s prescribing provider or his or her sta must answer questions 1-6 if requesting any type of absorbent
product. Answer question 7 if requesting pull-up or pull-on absorbent briefs. Answer question 8 if requesting absorbent
inserts or liners. Answer question 9 if requesting disposable or reusable absorbent underpads/bedpads. Answer
question 10 if requesting disposable and reusable underpad/bedpads to be used in conjunction with each other. Answer
question 11 if requesting quantities of absorbent products that exceed the limits in the
MassHealth DME and Oxygen
Payment and Coverage Guidelines Tool
. Section 6 must be filled in, and applicable supporting documentation
must be attached.
Section 7 The member’s prescribing provider listed in Section 2 of this form is required to review all information completed on
and attached to this form, and must sign and date the form. By signing the form, the prescribing provider is making the
certifications contained above the signature line. The form must be signed by the member’s prescribing provider,
who must be either the member’s physician (MD), nurse practitioner (NP), or physician assistant (PA).
The prescribing provider must check the applicable credential(s). Note: Signature and date stamps, or the
signature of anyone other than the prescribing provider, are not acceptable.
If you have any questions about how to complete this form, please contact the MassHealth Customer Service Center at 1-800-841-2900.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Mnr Absorbent (Commonwealth of Massachusetts)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 28 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document