Form Mnr-Ap - Masshealth Prescription And Medical Necessity Review Form For Absorbent Products

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MASSHEALTH PRESCRIPTION AND MEDICAL NECESSITY REVIEW FORM
Reset
FOR
ABSORBENT PRODUCTS
THE COMMONWEALTH OF MASSACHUSETTS
Executive Offi ce of Health and Human Services
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.: ___________________________________
MNR-AP (11/14)
continued on back

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