Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
www.mass.gov/masshealth
	
MassHealth
All Provider Bulletin 229
November 2012

TO:	All Providers Participating in MassHealth
FROM:	Julian J. Harris, M.D., Medicaid Director  
RE:	Physician Designees and the Ambulance Medical Necessity Form 



Background
The transportation Ambulance Medical Necessity Form is used to 
authorize medical necessity for wheelchair van trips for MassHealth 
members residing in an institutionalized setting and for nonemergency 
ambulance services for all eligible MassHealth Standard and 
CommonHealth members. See 130 CMR 407.421(D)(1). Ambulance 
Medical Necessity Forms require a valid authorized signature. See 130 
CMR 401.421(D)(2). Transmittal Letter TRN-31, issued in August 2009, 
inadvertently deleted “physician’s designee” from the list of authorized 
signatories. Individuals identified in 130 CMR 407.421(D)(2) prior to 
Transmittal Letter TRN-31 continue to be authorized to sign the 
Ambulance Medical necessity Form.


Authorized Ambulance Medical Necessity Form Signatories
Effective immediately and for prior periods otherwise affected by 
Transmittal Letter TRN-31, a physician, physician assistant, physician
designee, nurse midwife, dentist or dental third-party administrator, nurse 
practitioner, psychologist, or managed-care representative, may sign the 
Ambulance Medical Necessity 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.