Form Mnr-Enp - Masshealth Prescription And Medical Necessity Review Form For Enteral Nutrition Products

Download a blank fillable Form Mnr-Enp - Masshealth Prescription And Medical Necessity Review Form For Enteral Nutrition Products in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Mnr-Enp - Masshealth Prescription And Medical Necessity Review Form For Enteral Nutrition Products with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

MASSHEALTH PRESCRIPTION AND MEDICAL NECESSITY REVIEW FORM

Reset

ENTERAL NUTRITION PRODUCTS

FOR

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 (shaded below), 6, and 7 must be ﬁ lled out by the prescribing provider.

SECTION 1

Member Name

Date of Delivery

Address

Telephone No.

MassHealth ID No.

Date of Birth

Gender

Primary ICD Code

Description

Secondary ICD Code

Description

SECTION 2

Prescribing Provider’s Name

NPI No.

Address

Telephone No.

FAX No.

SECTION 3

Name of Provider of DME

NPI No.

Address

Telephone No.

Fax No.

SECTION 4

SECTION 4 A

Place checkmark beside item requested and enter the appropriate HCPCS code,

Must be completed by the member’s prescribing

modiﬁ er, and description of equipment.

provider or his or her staff .

Description of Items Being Requested

HCPCS Code

Modiﬁ er Calories

Units

No. of

Length of Need

per Day

per Day Monthly Reﬁ lls

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 falsiﬁ cation, omission, or concealment of any material fact 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)

MNR-ENP (11/14)



continued on back