Commonwealth of Massachusetts 

Executive Office of Health and Human Services 

Office of Medicaid 

www.mass.gov/masshealth 



 

 MassHealth 

 Durable Medical Equipment Bulletin 17 

 December 2010 

 

 

 TO: Durable Medical Equipment Providers Participating in MassHealth 

 

FROM: Terence G. Dougherty, Medicaid Director 

 

 RE: Guidelines for Medical Necessity Determination for Hospital Beds and 

 Prescription and Medical Necessity Review Form for Hospital Beds 

 

 



Background MassHealth has developed Guidelines for Medical Necessity 
Determination for Hospital Beds (Guidelines), which are one in a series 
of publications developed by MassHealth to identify the clinical 
information MassHealth needs to determine medical necessity. 
MassHealth has also developed a MassHealth Prescription and Medical 
Necessity Review Form for Hospital Beds, including instructions for 
completing the form. 

 

 

Guidelines for Medical MassHealth requires prior authorization (PA) for all hospital beds. 

Necessity Determinations MassHealth reviews requests for PA on the basis of medical necessity. 

for Hospital Beds The recently developed Guidelines identify the clinical information 
MassHealth needs to determine medical necessity for hospital beds and 
specialized pediatric beds used in the home. They are based on 
generally accepted standards of practice, review of the medical 
literature, and federal and state policies and laws applicable to Medicaid 
programs. The Guidelines were prepared for medical professionals, 
including providers of durable medical equipment, to assist them in 
submitting documentation to MassHealth justifying the medical 
necessity of the proposed products or services. 

 

 

Hospital Bed Prescription Effective with PA requests submitted on or after January 1, 2011, 

and Medical Necessity providers are instructed to use the new MassHealth Prescription and 

Review Form Medical Necessity Review Form for Hospital Beds when requesting PA 
for hospital beds. Please follow the form’s instructions. Providers must 
maintain a copy of the completed and signed form in the member’s 
medical record. 

 

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Where to Obtain Copies Both the Guidelines and the MassHealth Prescription and Medical 
Necessity Review Form for Hospital Beds can be viewed on the 
MassHealth Web site at www.mass.gov/masshealth. Click on the link in 
the lower right corner for MassHealth Guidelines for Medical Necessity 
Determination. At the bottom of that Web page is a link to all of the 
Medical Necessity Review Forms. The medical necessity review form 
for hospital beds is fillable and can be submitted online, or downloaded 
and submitted by mail. 

 

 

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.