Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth All Provider Bulletin 192 May 2009 To: All Providers Participating in MassHealth From: Tom Dehner, Medicaid Director RE: Revised Prescription for Transportation (PT-1) Form Background As part of preparation for NewMMIS implementation on May 26, 2009, the prescription for transportation (PT-1) form used by providers on behalf of members to request authorization for transportation to a medical appointment, has been revised. A few changes have been made to the form to reflect updates to the MassHealth transportation regulations. Changes to the PT-1 Form The following changes have been made to the PT-1 form. • Recipient ID is now called member ID, and is 12 characters long instead of 10. • The provider number is now MassHealth provider ID/service location, and the NPI field is also included. • Alternate address information is now included in Section 1, along with home and mailing address information. • Dental third-party administrator has been added to Section 8 as an authorized signature that MassHealth will accept on the form. The form continues to be fillable online. We encourage you to submit your PT-1 requests electronically instead of using the fax or mail. Using the New PT-1 You can start using the revised PT-1 form immediately. Form (continued on next page) MassHealth All Provider Bulletin 192 May 2009 Page 2 Requesting a Supply of the PT-1 Form You can request a supply of the PT-1 form online at www.mass.gov/masshealth. Click on Order Provider Publications in the Online Services box. You can also mail or fax a written request for supplies of this form at the address or fax number below. MassHealth ATTN: Forms Distribution P.O. Box 9118 Hingham, MA 02043 Fax: 617-988-8973 Attached is a sample of the revised PT-1 form. Questions If you have any questions about the information in this bulletin, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. Return completed form to: MassHealth Transportation Unit, P.O. Box 45, Boston, MA 02112-0045, or fax it to 617-988-2925. PRESCRIPTION FOR TRANSPORTATION FORM Please indicate the type of request: New form Renewal Increase in visits Alternate pick-up address Please print or type all information. 1. MassHealth Member Information Last name First name Date of birth Member ID Tel. no. HOME ADDRESS (The MassHealth member will be transported to and from this address, unless an alternate pick-up address is listed.) Street address Apt. no. City/Town State Zip ALTERNATE PICK-UP ADDRESS Street address Apt. no. City/Town State Zip MAILING ADDRESS (if different from home address) Street address Apt. no. City/Town State Zip 2. MassHealth Provider Information (Section to be completed by the provider requesting transportation.) 3. Name and Location of Treating Provider/Facility (Indicate where the MassHealth member will be seen.) Check if same as provider listed in Section 2. Name of treating provider/facility Tel. no. Ext. Street address Suite no. City/Town State Zip MassHealth provider ID/service location NPI Name of treating provider/facility Tel. no. Ext. Street address City/Town State Zip MassHealth provider ID/service location Is the treating facility within the member’s locality (city or town of residence, or adjacent city or town)? If No, please justify: NPI Yes No Is a wheelchair van needed? Yes No Is an escort accompanying the member for assistance with ambulation or to accompany a minor? Yes No Specify other transportation needs: 8. Provider/Dental TPA Signature Signature: Date: Please check applicable title: MD DDS RNP RNC Other (Specify title) Do not write below this line • MassHealth use only APPROVED. Authorization expires on: Tracking no.: DENIED. Reason: MassHealth authorized signature: Date: PT-1 (Rev. 05/09)