Medical Necessity Review Form for Hospital Beds (PDF) - Mass - mass 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1 by entering the date of delivery, member's details including name, address, MassHealth ID, and ICD codes. Ensure all fields are accurately filled to avoid denial.
3. Proceed to Section 2 and input the prescribing provider’s information such as name, NPI number, and contact details.
4. In Section 3, provide the DME provider's information similarly. This section is crucial for identifying who will supply the hospital bed.
5. For Section 4, checkmark the item requested and enter the corresponding HCPCS code and description. Be thorough in this section as it outlines what equipment is needed.
6. Section 5 requires the DME provider's signature and date. Ensure that this is completed correctly to validate the form.
7. Sections 6 and 7 must be completed by the prescribing provider. Answer all applicable questions regarding medical necessity and ensure supporting documentation is attached.

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