130 CMR, § 442.409 - Prescribing Provider Orders and Other Documentation Requirements

(A) Initial Orders. The initial order may be written, verbal, or electronically transmitted (in accordance the applicable federal and state laws, rules and guidance) by the member's prescriber. A verbal initial order must be simultaneously documented in writing by an employee of the provider of orthotics.

(1) The verbal, written, or electronically transmitted initial order must include:

(a) the date the provider of orthotics obtains or receives the initial order from the prescribing provider;

(b) a general description of the orthotic service that is the subject of the initial order

(c) the member's name;

(d) the name of prescribing provider giving the initial order; and

(e) the name and title of the employee of the provider of orthotics who obtained or received the initial order, and in the case of a verbal initial order, documented the initial order in writing.

(2) Orthotics providers must maintain a copy of the initial order (or written documentation of a verbal initial order) in the member's record and make this information available to MassHealth upon request.

(B) Detailed Written Order. The provider of orthotics must obtain a detailed written order signed and dated by the member's prescribing provider for all orthotic services provided to a member prior to the date the claim is submitted to MassHealth for the orthotic services, or in the case of orthotic services requiring prior authorization, prior to the date that the prior authorization request is submitted to the MassHealth agency or its designee. The detailed written order must comply with the requirements for a legal prescription under all applicable federal and state laws and regulations, and also contain a statement of medical necessity. If the detailed written order is prepared by the orthotics provider, the detailed written order must be reviewed, signed and dated by the prescribing provider. The detailed written order must contain an attestation whereby the prescribing provider certifies under pains and penalties of perjury, that he or she is the prescribing provider identified on the detailed written order; that the medical necessity information on and attached to the detailed written order is true, accurate, and complete to the best of his or her knowledge, and that the prescribing provider may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact pertaining thereto. For specific orthotic services, additional requirements apply as set forth in 130 CMR 442.409(B)(1) and (2).

(1) Shoes and Related Services.

(a) For therapeutic shoes, inserts, and modifications for diabetics, the orthotics provider and the prescribing provider must complete and sign the MassHealth Orthotic and Prosthetic Prescription and Medical Necessity Review Form for Therapeutic Shoes, Inserts, and Modifications (for diabetics) (Form ORT-D), adopted by MassHealth. This form serves as the detailed written order and statement of medical necessity. As a condition of payment, a copy of the completed form must be submitted to MassHealth with the provider's claim. The completed form must be maintained in the member's record.

(b) For foot orthoses, footwear (inclusive of orthopedic shoes) and modifications for non-diabetic members, the prescribing provider must complete and sign the MassHealth Orthotic and Prosthetic Prescription and Medical Necessity Review Form for Foot Orthoses, Footwear, and Modifications (for non-diabetics) (Form ORT-ND), adopted by MassHealth, in accordance with MassHealth instructions. This form serves as the detailed written order and statement of medical necessity. As a condition of payment, a copy of the completed form must be submitted to MassHealth along with the provider's claim. The completed form must be maintained in the member's record.

(2) Orthotic Services Other than Shoes. For orthotics other than shoes, shoe inserts and modifications, the detailed written order may be prepared by the provider of orthotics, but must be reviewed, signed and dated by the member's prescribing provider. MassHealth medical necessity guidelines for specific orthotics require that the detailed written order be signed by specified medical professionals. The detailed written order must be maintained in the member's record. In addition to meeting the requirements in 130 CMR 442.409(B), the detailed written order must include, at minimum, the following information:

(a) the member's name and address;

(b) the member's MassHealth identification number;

(c) specific identification of the prescribed item, including all options or additional features that will be separately billed;

(d) the member's diagnosis;

(e) a statement of medical necessity;

(f) the prescribing provider's address and telephone number; and

(g) the date on which the prescribing provider signed the detailed written order.

(C) Exception for Repairs of Items Purchased by MassHealth. The MassHealth agency does not require an initial order or a detailed written order for the repair of an orthotic by the provider who initially supplied the item to be repaired.

Notes

130 CMR, § 442.409

Amended by Mass Register Issue 1395, eff. 7/12/2019.