Form Mnr-Nat - Masshealth Medical Necessity Form For Wheelchair Van Transportation (Page 2 of 2) in pdf

6a. Medical Necessity Information—Wheelchair Van Requests Only

Member resides in an institutionalized setting and uses a wheelchair

Member resides in an institutionalized setting and has a severe mobility impairment preventing member from using other transportation

Member resides in an institutionalized setting and needs to be carried up or down stairs (because member is unable to walk up or down

stairs or cannot walk without the assistance of two persons)

Member resides in the community and needs mobility assistance from transportation provider personnel to exit his or her residence or to

move from his or her residence to the vehicle

Member is being discharged from an inpatient psychiatric hospital to a community-based behavioral health program and requires

supervision during transportation. PT-1 transportation is unavailable or inappropriate.

6b. Medical Necessity Information—Ambulance Requests Only

Member is continuously dependent on oxygen.

Member is continuously confined to bed.

Member is classified as an American Heart Association Class IV patient with a disease of the heart.

Member is receiving intravenous treatment.

Member requires transportation after cardiac catheterization.

Member has uncontrolled seizure disorders.

Member has a total body cast.

Member has hip spicas or other casts that prevent flexion at the hip.

Member is in an isolette (incubator).

Member is in need of restraints because the member is possibly harmful to himself or herself or others. (This includes persons transported

under M.G.L. c. 123, § 12 for temporary hospitalization by reason of mental illness.)

Member is heavily sedated.

Member is comatose.

Member has the following medical condition making ambulance transportation necessary.

7. Requesting Provider Attestation

NOTE: The requesting provider must 1) have adequate knowledge of the member’s condition to attest to the information contained in

the form; 2) be one of the provider types identified below; and 3) be enrolled in MassHealth (or, in the case of a physician designee, be a

registered nurse supervised by a physician who is enrolled in MassHealth).

ATTESTATION: 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 is true, accurate, and complete, to the best of my knowledge. I also certify that I am the provider identified

below. 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.

Signature

Date

Print name

NPI (if applicable)

Tel. #

Fax #

Provider Type:

Dentist

Managed care representative

Nurse midwife

Nurse practitioner

Physician

Physician assistant

Physician designee (Registered Nurse)

Psychologist

Physician designees only: Provide the following information for supervising physician.

Name

NPI

Tel. #

Fax #

Form Mnr-Nat - Masshealth Medical Necessity Form For Wheelchair Van Transportation Page 2

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