Masshealth necessity form 2026

The document is a General Prescription and Medical Necessity Review Form for Durable Medical Equipment (DME) and medical supplies, which must be completed by both the DME provider and the prescribing provider. It includes sections for member information, prescribing provider details, DME provider information, requested items with HCPCS codes, medical justification, and attestation signatures. The form is used to obtain prescriptions and letters of medical necessity for DME and serves as an attachment for prior authorization requests.

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Click ‘Get Form’ to open the masshealth necessity form in the editor.
Begin with Section 1, where you will enter the member’s information including their name, MassHealth ID number, address, telephone number, date of birth, gender, height, weight, ICD codes, and diagnosis.
Proceed to Section 2 to input the prescribing provider’s details such as their name, address, telephone number, NPI, and fax number.
In Section 3, fill in the DME provider’s information including their name, address, telephone number, NPI, and fax number.
For durable medical equipment requests in Section 4A and additional items in Section 4B if needed, list the items requested along with their HCPCS codes and modifiers. Specify the length of need for each item.
In Section 5A for medical supplies, detail the items requested along with their HCPCS codes and specify monthly quantities and refills.
Complete Section 6 by providing medical justification for the requested items and attach any relevant documentation.
Finally, ensure that Sections 7 is signed and dated by the prescribing provider to certify accuracy.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (71 Votes)
2014	4.2 Satisfied (63 Votes)

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