Dme Form PDF Details

In the realm of healthcare, effective communication and documentation between providers and suppliers are paramount, especially when it comes to the procurement of durable medical equipment (DME) and medical supplies. The Durable Medical Equipment and Medical Supplies General Prescription and Medical Necessity Review Form serves as a crucial bridge in this process, ensuring that individuals receive the appropriate medical equipment or supplies tailored to their health needs. This form is methodically divided into sections, each requiring specific information from the DME provider and the member's prescribing provider. The initial sections gather essential information about the member, the prescribing provider, and the DME provider. Meanwhile, subsequent sections delve into more detailed information such as the type of equipment or supplies requested, including the Healthcare Common Procedure Coding System (HCPCS) codes, quantities, and detailed medical justifications for the requested items. Completing this form accurately is not only vital for adherence to MassHealth regulations and requirements but also for facilitating a seamless delivery of services to the member. It underscores the necessity for meticulous attention to detail from both the DME providers and the prescribing professionals to ensure that submitted requests are comprehensive, accurate, and duly compliant with regulatory standards, highlighting the shared responsibility in promoting patient care and welfare.

QuestionAnswer
Form NameDme Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesmassachusetts dme, dme masshealth, massachusetts durable medical equipment, masshealth form for absorbent products

Form Preview Example

Durable Medical Equipment and Medical Supplies

General Prescription and Medical Necessity Review Form

Date of Delivery

Sections 1-5 must be completed by the DME provider. Sections 4A, 4B, 5A, 6, and 7 must be completed by the member’s prescribing provider.

Section 1 — Member’s Information

Member’s name

 

 

 

 

 

 

MassHealth ID no.

 

 

 

 

Address

 

 

 

 

 

 

 

Tel. no.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth (dd/mm/yy)

 

Gender

 

 

 

 

 

Height

 

 

Weight

 

 

ICD code(s) ___________/__________/__________/___________/__________/__________

 

 

 

 

 

 

 

 

 

Diagnosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 2 — Prescribing Provider’s Information

Prescribing provider’s name

 

 

Tel. no.

 

 

Address

 

 

 

NPI

 

 

 

 

 

 

 

 

 

Fax no.

 

 

 

Section 3 — DME Provider Information

DME provider name

 

 

 

 

 

 

 

 

 

 

Tel. no.

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

NPI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fax no.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 4 — For Durable Medical Equipment Only

 

 

 

 

 

Section 4A (Must be completed by prescribing provider or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the prescribing provider’s employee.)

Items Requested

HCPCS Code

 

Modifiers

 

 

Length of Need

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

 

5.

 

 

 

 

 

 

 

 

 

 

6.

 

 

 

 

 

 

 

 

 

 

 

 

 

(See page 2 Section 4B, for additional listings.)

 

 

 

 

 

 

 

 

Section 5 — For Medical Supplies Only

 

 

 

 

 

 

Section 5A (Must be completed by prescribing provider or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the prescribing provider’s employee.)

Items Requested

HCPCS Code

 

Modifiers

 

 

Quantity Monthly

 

 

Number of Refills

1.

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 6

Medical justification for requested item(s) along with any settings, therapeutic outcomes, and previous treatment plans (if applicable). Please attach any pertinent documentation (i.e., lab tests, etc.).

Section 7 — Prescribing Provider’s Attestation, Signature, and Date

I certify that I am the prescribing provider identified in Section 2 of this form. Any attached statement on my letterhead has been reviewed and signed by me. I certify that the medical necessity information (per 130 CMR 450.204) on this form is true, accurate, and complete, to the best of my knowledge. I understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.

Prescribing provider’s signature

(Signature and date stamps are not acceptable)

Date

 

 

CONTINUED

DME-2 (REV. 11/19)

 

 

Section 4B: For additional listings, if needed

ITEMS REQUESTED

Quantity

HCPCS

Modifier

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

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 it 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 falsification, omission, or concealment of any material contained herein. Note: 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 the legal entity, are not acceptable.

Provider of DME’s signature _______________________________________________________________

Printed legal name of provider _____________________________________________________________

Printed legal name of individual signing ____________________________________________________

Date _________________________________

PAGE 2

Instructions for Completing the Durable Medical Equipment and Medical Supplies General Prescription and Medical Necessity Review Form

(Sections 1, 2, 3, 4, and 5 must be completed by DME provider.)

Instructions for Use of this Form

DME providers should use this form when obtaining a prescription and letter of medical necessity from the

 

member’s prescribing provider for DME, and as an attachment to a prior authorization request. This form will

 

not be accepted in certain circumstances, such as when a MassHealth Medical Necessity Review Form exists

 

for specific DME (such as absorbent products, enteral products, and support surfaces products). The DME

 

provider is responsible for ensuring compliance with applicable MassHealth regulations and requirements when

 

completing this form. MassHealth reserves the right not to accept the form if it is completed improperly, or if

 

the DME provider has failed to meet applicable MassHealth regulations, requirements, and guidelines.

 

 

Date of Delivery

Enter the date of service.

 

 

Section 1

Enter the member’s name, MassHealth member ID number, home address (including apartment number if

 

applicable), telephone number, date of birth, gender, height, weight, ICD code(s), and diagnosis that pertain

 

to the items being dispensed.

 

 

Section 2

Enter the prescribing provider’s name, telephone number, address, NPI, and fax number.

 

 

Section 3

Enter the DME provider’s name, telephone number, address, NPI, and fax number.

 

 

Section 4

This section is for durable medical equipment only. Enter the description of the item(s) being supplied, the

 

HCPCS code, and the appropriate modifier(s) being used for billing, as applicable. Providers of DME that need

 

additional space in Section 4 may use Section 4 B (page 2), which is a continuation of Section 4.

 

 

Section 5

This section is for medical supplies only. Enter the description of the item(s) being supplied, the HCPCS code,

 

and the appropriate modifier(s) being used for billing, as applicable.

 

 

Sections 4A, 5A, 6, and 7 must be completed by prescribing provider.

Section 4A, 5A

Enter the length of need (in months).

 

 

Section 5A

Enter the monthly quantity and the number of refills (in months).

 

 

Section 6

Enter the medical justification for all items listed above. Include (if applicable) settings, therapeutic outcomes,

 

and previous treatment plans. Attach any applicable supporting medical documentation (i.e., lab tests, etc.).

 

 

Section 7

The prescribing physician, nurse practitioner, or physician assistant, as appropriate, must sign and date the

 

form. By signing the form, the prescribing provider is making the certifications contained above the signature

 

line.

 

 

If you have any questions about how to complete this form, please call the MassHealth Customer Services Center at (800) 841-2900.

PAGE 3

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1. You need to complete the durable medical equipment necessity correctly, so take care while filling out the areas comprising these fields:

Part number 1 in completing dme form

2. The next part is usually to submit the next few blank fields: Modifiers, Length of Need See page, Section A Must be completed by, Quantity Monthly, Number of Refills, Items Requested, Section For Medical Supplies Only, Items Requested, HCPCS Code, Section Medical justification for, and Section Prescribing Providers.

Section A Must be completed by, Modifiers, and HCPCS Code of dme form

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Step number 3 for filling in dme form

4. Now start working on this next segment! Here you've got these Provider of DME Attestation, I certify under the pains and, Provider of DMEs signature, and Printed legal name of provider blanks to complete.

Provider of DME Attestation, Provider of DMEs signature, and I certify under the pains and inside dme form

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Step number 5 for completing dme form

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