Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 407.000 - Transportation Services
Section 407.421 - Authorization for Transportation

(1) All forms of transportation, except public transportation, require authorization consisting of one or more of the following:

(2) Specific authorization requirements for each mode of transportation are provided in the sections of regulations for each mode of 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:

(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.