Please find Health Safety Net (HSN) Pharmacy-related materials below including the 90-Day Waiver Form, Drug Prior Authorization Request Form, and Pharmacy Specifications Guide.

Important Notes

Outpatient pharmacy services are only reimbursable by the HSN if they are:

  • provided to an HSN-eligible patient AND
  • are provided by a pharmacy
    • owned by an acute hospital or community health center or contracting with an acute hospital or community health center AND
    • enrolled with HSN

Providers must comply with all applicable provisions of HSN regulations, including participation as a MassHealth provider as well as the 340B Program if eligible.

Materials and Related Information

90-Day Waiver Form (PDF) pdf format of 2009-90-day-waiver-dhcfp-logo-03-05.pdf
doc format of                             2009_90-day_waiver_dhcfp_logo_03-05.doc

  • The 90-Day Waiver Form should be used for all requests to waive the requirement that a given claim be submitted within 90 days of the date of service.
  • Circumstances justifying a waiver include:
    • rebilling a previously denied timely filed claim
    • retroactive member enrollment
    • retroactive provider enrollment

Form to Become a New HSN Pharmacy pdf format of HSN New Pharmacy Form
doc format of                             HSN New Pharmacy Form                (Whenever possible, please use the fillable form PDF.)

  • The setup process (including testing) must be completed with MassHealth before the form can be completed in full. For questions about setting up the pharmacy with MassHealth, please contact MassHealth. For questions about setting up the pharmacy with the Health Safety Net, please contact the HSN Provider Help Desk via email (HSNHelpDesk@massmail.state.ma.us) or via phone (800-609-7232).

Special Circumstances Pharmacy Claims Specifications (PDF) pdf format of 2009-pharmacy-specs-03-03.pdf
doc format of                             2009-pharmacy-specs-03-03.doc

  • These specifications are for the electronic billing of pharmacy services provided to Special Circumstances patients. The Special Circumstances Pharmacy Claims filing is limited only to claims for prescriptions filled for patients for whom the medical provider (i.e., community health center or acute hospital) has filed an HSN Special Circumstances Application. Eligibility for HSN coverage is defined in 101 CMR 613.04 and includes Confidential Services patients including minors and battered and abused victims. Pharmacy claims for these Special Circumstances can not be submitted through POPS.
  • The Virtual Gateway/MA-21 process does not determine eligibility for those Special Circumstances patients eligible to receive HSN coverage. POPS or EVS will not show the HSN eligibility for these patients. Filing a claim through POPS may violate the confidential status of these Special Circumstances patients. Medical providers must clearly identify all Special Circumstances prescriptions to the HSN-eligible pharmacy so they can be filled and documented properly. At this time, pharmacies should not collect co-pay amounts from patients eligible for HSN Special Circumstances services.
  • Providers submit pharmacy claims for these Special Circumstances-eligible services on a monthly basis using the Special Circumstances Pharmacy INET Application. The HSN claims processing system will check that the patient has a Special Circumstances Application on file and is eligible to receive the services. Pharmacy claims submitted through the Special Circumstances Pharmacy INET Application will be processed after the close of the month in which they are received and payments will be included in the following month's disbursements.
  • See Prior Authorization Forms for Medicaid Pharmacy Services
    - for forms for all Prior Authorization (PA) requests where PA is required by MassHealth; the HSN follows the MassHealth rules for PA.