Prescription For Transportation Form - … You'll find all forms we currently use in the following list. We're currently reviewing all forms in an effort to make it easier and simpler to work with us, so check ...
Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA
02111 2009 Background As part of preparation for NewMMIS implementation on May 26, 2009, the prescription for transportation (PT-1) form used by providers on behalf of members to request authorization for transportation to a medical appointment, has been revised.A few changes have been made to the form to reflect updates to the MassHealth transportation regulations.The following changes have been made to the PT-1 form.
Recipient ID is now called member ID, and is 12 characters long instead of 10.
The provider number is now MassHealth provider ID/service location, and the NPI field is also included.
Alternate address information is now included in Section 1, along with home and mailing address information.
Dental third-party administrator has been added to Section 8 as an authorized signature that MassHealth will accept on the The form continues to be fillable online.We encourage you to submit your PT-1 requests electronically instead of using the fax or mail.
You can start using the revised PT-1 form immediately(continued on next page)MassHealth All Provider Bulletin 192 May 2009 www.mass.gov/masshealth.Click on Order Provider Publications in You can also mail or fax a written request for supplies of this form at the address or fax number below.MassHealth ATTN: Forms Distribution P.O.Box 9118 Attached is a sample of the revised PT-1 form.
If you have any questions about the information in this bulletin, please contact MassHealth Customer Service at 1-800-841-2900, firstname.lastname@example.org, or fax your inquiry to 617-988-8974. APPROVED.Authorization expires on: Tracking no.:
DENIED.Reason: MassHealth authorized signature: Date: Name of treating provider/facilityTel.no. Ext.Street address Suite no.
City/Town State Zip Please list the MassHealth-covered service(s) that the member is receiving at this location.How long will the MassHealth member require these ) per week visit(s) per monthIs there a medical reason why the member (or guardian if accompanying a minor) is unable to use public transportation? Yes NoIf Yes, please describe specic medical reason: Is a wheelchair van needed? Yes NoIs an escort accompanying the member for assistance with ambulation or to accompany a minor? Yes NoSpecify other transportation title) Name of treating provider/facility Tel.no. Ext.Street address City/Town State Zip Is the treating facility within the members locality (city or town of residence, or adjacent city or town)? Yes If No, please justify:2.MassHealth Provider Information (Section to be completed by the provider requesting transportation.)4.
Medical Treatment Type5.Duration and Frequency of Treatment6.
Why Transportation Services Are Required7.Other Information8.Provider/Dental TPA Signature3.Name and Location of Treating Provider/Facility (Indicate where the MassHealth member will be seen.) Check if same as provider listed in Section 2.1.MassHealth Member InformationLast name First name Date of birthMember ID Tel.
no.HOME ADDRESS (The MassHealth member will be transported to and from this address, unless an alternate pick-up address is listed.)Street address Apt.no.City/Town State ZipALTERNATE PICK-UP ADDRESSStreet address Apt.no.City/Town State ZipMAILING ADDRESS (if different from home address)Street address Apt.no.
City/Town State ZipPRESCRIPTION FOR TRANSPORTATION FORM New in visits
Alternate pick-up addrePT-1 (Rev. completed form to: MassHealth Transportation Unit, P.O.Box 45, Boston, MA
02112-0045, or fax it to 617-988-2925
.Instructions for Completing the Prescription for Transportation FormSection 1 Enter the members name, date of birth, MassHealth member ID, telephone number, and home address, including apartment number, if applicable.In certain circumstances MassHealth may authorize a member to be picked up at an address other than his/her home address.If the member is to be picked up at an alternate address, enter the alternate address information below the home address information.
If there is a mailing address that is different from the home address, enter that below the alternate pick-up address.Section 2 Enter the providers name, telephone number, address, MassHealth provider ID/Service location, and the NPI.The provider requesting transportation must be a physician, physicians assistant, nurse midwife, dentist, nurse practitioner, psychologist, or managed-care representative, and an active MassHealth provider.Section 3 If the provider is also the treating provider, place a checkmark in the box labeled Check if same as provider listed in Section 2. If the treating provider is different from the provider lling out Section 2, enter that providers name, telephone number, address and, if known, their MassHealth provider ID Service location,
If the treatment destination is outside of the members locality (city or town of residence, or immediately adjacent communities), indicate why the medical care is unavailable to the member within the members locality.Section 4 Describe the specic medical care that will be provided.Section 5 Indicate how many weeks or months the member will require transportation, and how frequently the member will be going per week or per month for the service.
MassHealth will not authorize more than six months of transportation for an acute illness, or one year of transportation for a chronic illness.For a single visit, enter 1 week, and 1 visit per week.Section 6 Indicate if there is a medical reason that the member (or guardian, in accompanying the member) is unable to use public transportation.Provide the specic physical o
Massachusetts Administrative Simplification CollaborativeStandardized Prior Authorization Request Form V1.1 May 2012 Standardized Prior Authorization Request Form Acute Medical/Surgical Enteral Nutrition Infant FormulaAddress:Phone: Massachusetts Administrative Simplification CollaborativeStandardized Prior Authorization Request Form Reference Guide V1.0
Standardized Prior Authorization Request FormReference GuideSave for AetnaMassachusetts Administrative Simplification CollaborativeStandardized Prior Authorization Request Form Reference Guide V1.0
Capture supporting clinical documentation.- Including plans specific templates.STANDARDIZED PRIOR AUTHORIZATION REQUEST FORM REFERENCE GUIDEThe Standardized Prior Authorization Request Form is not intended to replace payer specific prior authorization procedures, policies and documentation requirements.For payer specific policies, please reference the payer specific websites.Massachusetts Administrative Simplification CollaborativeStandardized Prior Authorization Request Form Reference Guide V1.0
Defining Data Elements
The requesting provider is the physician and the servicing provider can be the same
CPT codes are not required by every plan, but are required by some.
Please consult the - Hours: Home health aide- Days:
Home health; physical therapy- Months:
Outpatient therapies; home health (RN, PT, OT)- Dosage:
Different measurements (mg, g, etc.) that can be used for infusion
Any supporting clinical documentation should be submitted in addition to this form for
For services not listed, please refer to plan specific medical policies for prior authoriza-
Some services may require physician signature and should be submitted with the sup-for services that require prior PRIOR AUTHORIZATION REQUEST FORM REFERENCE GUIDE (continued)
Neighborhood Health PlanClear .
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