Authorization for Transportation

(A) Types of Authorization. (1) All forms of transportation except public transportation require authorization consisting of one or more of the following: (a) verbal authorization for transportation following submission of a Provider Request for Transportation (PT-1) as described in 130 CMR 407.421(A)(1)(b) or when urgent care is needed; (b) a Provider Request for Transportation (PT-1) completed in accordance with 130 CMR 407.421 (C) submitted by an authorized provider, a day habilitation program representative, an early intervention program representative, or a managed-care representative, and approved by MassHealth; or (c) a Medical Necessity Form completed in accordance with 130 CMR 407.421(D) and signed by an authorized provider or a managed-care representative, or, only for members transported for hospitalization under M.G.L. c. 123, § 12, a completed and signed Department of Mental Health Application for and Authorization of Temporary Involuntary Hospitalization. (2) Specific authorization requirements for each mode of transportation are provided in the sections of regulations for each mode of transportation. (B) Authorization for Out-of-state Transportation. Transportation to specially approved out-of- state medical services requires prior authorization from the MassHealth agency. Transportation to these out-of-state medical services must be the least costly mode suitable to the member's condition. (C) Provider Request for Transportation. (1) The Provider Request for Transportation (PT-1) form must be used to request authorization for brokered transportation. (2) A Provider Request for Transportation (PT-1) form must be completed and submitted by an authorized provider, managed-care representative, day habilitation program representative, or early intervention program representative, and approved by MassHealth. (3) A completed PT-1 must contain: (a) adequate information to determine the need for the transportation requested and that the member will receive a medically necessary service covered by MassHealth at the trip’s destination; and (b) if recurring transportation is requested, the expected duration of the need for transportation (specific time period not to exceed six months for acute illness; one year for chronic illness; three years for early intervention and five years for day habilitation). (D) Medical Necessity Form. (1) The Medical Necessity Form is used to document the medical necessity of fee-for-service transportation services. The member’s medical record must support the information given on the Medical Necessity Form. For members transported for hospitalization under M.G.L. c. 123, § 12, a completed and signed Department of Mental Health Application for and Authorization of Temporary Involuntary Hospitalization may be accepted in place of the Medical Necessity Form. (2) The transportation provider is responsible for ensuring that the Medical Necessity Form is signed by an authorized provider or managed-care representative and completed in accordance with 130 CMR 407.421(D). The completed Medical Necessity Form must be kept by the transportation provider as a record for six years from the date of service. (3) A completed Medical Necessity Form must contain adequate information to determine the need for the transportation requested and that the member will receive a medically necessary service covered by MassHealth at the trip’s destination. (4) When a member must travel more than once to the same destination in a 30-day period, all trips for the 30-day period may be authorized on one Medical Necessity Form. The anticipated dates of each trip and the anticipated total number of trips must be entered on the form. (130 CMR 407.422 through 407.430 Reserved.)