Requirements for Prescriptions or Letters of Medical Necessity Completed by the Ordering

Practitioner (A) LOMN and Prescription. The DME provider must obtain either a prescription or letter of medical necessity (LOMN), or a combination of a prescription and LOMN for the purchase or rental of DME. The prescription, LOMN, or a combination of a prescription and LOMN that meets the requirements of 130 CMR 409.416, must be in writing, signed by the ordering practitioner, and dated prior to the date the claim is submitted to the MassHealth agency. For certain DME that requires a prescription by specified medical professionals, the prescription or LOMN must be signed by such medical professionals. If the DME requires prior authorization, the prescription or LOMN must be dated prior to the date the prior authorization request is submitted to the MassHealth agency. (B) Required Prescription or LOMN Information. The initial and subsequent prescriptions or the LOMN must contain the following information, as applicable, with the exception of item (5), which may be provided in additional supporting documentation: (1) the member’s name; (2) the date of the prescription; (3) the name and quantity of the prescribed item and the number of refills (if appropriate); (4) the name, NPI number, and signature of the ordering practitioner and date signed; (5) medical justification for the item(s) being requested, including diagnosis or ICD-10 code; (6) the equipment settings, hours to be used per day, options, or additional features, as they pertain to the equipment; (7) length of need; (8) the expected outcome and therapeutic benefit of providing the requested item(s) or treatment, when requested; and (9) a summary of any previous treatment plan, including outcomes, that was used to treat the diagnosed condition for which the prescribed treatment is being recommended, upon request. (C) Prescription or LOMN Formats. The MassHealth agency accepts either written prescriptions or letters of medical necessity for DME in the following formats, provided the requirements of 130 CMR 409.416(B) are met. (1) If the MassHealth agency has published a MassHealth Medical Necessity Review form for specific DME, providers may use the MassHealth Medical Necessity Review form as the prescription and letter of medical necessity specific to the DME being furnished. These forms can be found on the MassHealth website. (2) If the forms described in 130 CMR 409.416(C)(1) are not used by the DME provider, the MassHealth agency accepts prescriptions and letters of medical necessity written on one of the following, if the form and format include all requirements in 130 CMR 409.416(B); and comply with MassHealth administrative and billing regulations and instructions; and state and federal law and regulations: (a) the ordering practitioner’s prescription pad; (b) the ordering practitioner’s letterhead stationery; (c) the hospital prescription pad, if the member is being discharged from a hospital; (d) electronic prescriptions (escripts) that comply with state and federal requirements; (e) the MassHealth agency’s Durable Medical Equipment and Medical Supplies General Prescription and Medical Necessity Review Form (DME-2), unless there is a product- specific Medical Necessity Review form as stated in 130 CMR 409.416(C)(1); or (f) the Region A Durable Medical Equipment Carrier (DME Medicare Administrative Contractor (MAC)) Certificate of Medical Necessity (CMN) completed in accordance with the instructions established by the Region A DME MAC and in compliance with 130 CMR 409.416(A). (3) For prescription and letter of medical necessity requirements for members residing in nursing facilities, see 130 CMR 409.416(E). (D Electronic Transmission of Prescriptions. Prescriptions may be transmitted electronically to the DME provider by the member’s ordering practitioner in accordance with the MassHealth agency’s administrative and billing instructions and applicable state and federal laws. (E) Documentation for Prescriptions for Members in Nursing Facilities. For members residing in nursing facilities, the prescription is the actual order in the member’s medical record. The prescription must include a copy of the current month’s order sheet that is signed and dated by the ordering practitioner, a copy of the medical justification from the member’s nursing facility record, and must include any additional documentation necessary to support medical necessity. Additional documentation may include physician progress notes; relevant laboratory or diagnostic test results; nursing, nutrition, or therapy assessments and notes; or wound assessments with pictures done with specialized wound photography. (F) Refills of DME. (1) The MassHealth agency may allow payment of refills of DME prescribed up to a maximum of 12 months. (2) The absence of an indication to refill by the prescriber renders the prescription nonrefillable. (3) The MassHealth agency does not pay for any refill without approval from a member or member’s authorized representative, provided at the time the prescription is to be refilled. The possession by a provider of a prescription with remaining refills does not constitute approval from the member to refill the prescription. (4) The DME provider must keep records of all member or authorized representative approval of refills in accordance with 130 CMR 409.430(L).