(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.
