Instructions for Completing the MassHealth Prescription and Medical Necessity Review Form
for Enteral Nutrition Products
Sections 1, 2, 3, and 4 must be completed by the provider of DME or the prescribing provider. Section 5 must be completed by the provider of DME.
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 enteral nutrition products, and as an attachment to a prior authorization (PA)
request for enteral nutrition 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 Enteral Nutrition Products
for further information about required
clinical documentation and information that must be submitted for PA requests for enteral nutrition 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 oce and at the provider of DME’s oce.
Section 1 MassHealth does not require the date of delivery to be completed at the time the PA is submitted to MassHealth, but
it must be entered on the form for record keeping purposes. The date of delivery at the top of the page on this form
must match the date of initial delivery on the delivery slip. Enter the member’s name, MassHealth member ID number,
address (including apartment number if applicable), telephone number, date of birth, gender, and applicable ICD
diagnosis codes with their descriptions.
Section 2 Enter the prescribing provider’s name, NPI, address, telephone, and fax numbers.
Section 3 Enter name of provider of DME, NPI, address, telephone, and fax number.
Section 4 Enter the description of the enteral formulae and supplies being requested, the HCPCS codes, and the modifiers.
Section 5 The provider of DME must sign and enter the date the form was completed. By signing the form, the provider is making
the certifications contained above the signature line. Signature and date stamps, the signature of anyone other
than the provider of DME 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 If the member is being tube fed (BA modifier), the prescribing provider must enter the number of calories per day that
the member is expected to obtain from the enteral formulae listed. If the member requires oral enteral nutrition (BO
modifier), enter the units (1 unit = 1 can) of enteral products requested per day. Enter the length of need (in months)
that the prescribing provider expects the member to require use of products and supplies requested (not to exceed 12
months from the date of the original prescription).
Section 6 The member’s prescribing provider or the provider’s sta must complete the medical justification for the requested
product(s). This section 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 must 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 credentials. 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.
