Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

MASSHEALTH
TRANSMITTAL LETTER ORT-15
December 2002
TO:      Orthotic Providers Participating in MassHealth FROM:      Wendy E. Warring, Commissioner
RE:      Orthotics Manual (Age Limitations for Orthotic Services)
Beginning January 1, 2003, MassHealth will no longer cover orthotic services for adult MassHealth members who are 21 years of age or older, except for members with severe diabetic foot disease. The Division’s current budget appropriation requires these changes, at a minimum, to cover expected deficiencies.
The attached regulations, which describe these changes, are effective January 1, 2003.
Claims for Custom-Made Goods
As stated in 130 CMR 450.231(B), “the ‘date of service’ is the date on which a medical service is furnished to a member or, if the medical service consists principally of custom-made goods such as eyeglasses, dentures, or durable medical equipment, the date on which the goods are delivered to a member. If a provider delivers medical goods to a member, which goods had to be ordered, fitted, or altered for the member, and that member ceases to be eligible for such MassHealth services on a date prior to the final delivery of the goods, the Division will reimburse the provider for the goods…”
Providers must submit paper claims for these services with all applicable documentation outlined in 130 CMR 450.231(B) to the following address.
Division of Medical Assistance Claims Operations Unit Attention: After Cancel Unit 600 Washington Street Boston, MA 02111
Billing Requirements and Reminders
This new age limitation presents some new billing requirements. Below are billing requirements and reminders to ensure that your claims for covered services are processed appropriately.
•    To ensure that your claims for orthotic services for members with severe diabetic foot disease are correctly identified, you must indicate the member’s diagnosis on the claim. Enter an ICD-9-CM diagnosis code that accurately describes the member’s condition in Item 21 of claim form no. 9, and the corresponding diagnosis name in Item 22. This diagnosis requirement is effective for dates of service on or after January 1, 2003.

MASSHEALTH
TRANSMITTAL LETTER ORT-15 December 2002 Page 2
 •	All claims for orthotic services, regardless of the member’s age, must be accompanied by a completed Shoe Medical Necessity Form.
 •	As a reminder, the Division pays for podiatry services only when a member’s primary care physician certifies on letterhead that such services are medically necessary for the life and safety of the member. This limitation extends to equipment and supplies prescribed by podiatrists.
 •	As always, it is important to enter the member’s primary care clinician’s (PCC) referral number in Item 8 on claim form no. 9, if the member is enrolled with a PCC.
DMA Web Site
This transmittal letter and attached regulations are available at the Division’s Web site at www.mass.gov/dma.
Questions
If you have any questions about this transmittal letter, please contact MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Othotics Manual
Pages 4-3 and 4-4
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Orthotics Manual
Pages 4-3 and 4-4 — transmitted by Transmittal Letter ORT-14

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 442.000)	PAGE
4-3	

	TRANSMITTAL LETTER
ORT-15	DATE
01/01/03	
Pedorthic Service — the design, manufacture, modification, and fitting of orthopedic or diabetic shoes, including foot orthosis, prosthetic fillers, and orthotic or pedorthic appliances for use from the ankle and below, provided in accordance with 130 CMR 442.000.
Service Facility — the place of business physically accessible to MassHealth members where orthotic or pedorthic services, especially those involving fitting, adjustment, repair, and replacement of orthoses, are performed. A service facility does not include a MassHealth member’s place of residence.
Split-Size Charge — an additional charge for dispensing an off-the-shelf, medical-grade pair of orthopedic shoes, where one shoe in the pair is a different size or width than the other shoe in the pair.
442.403: Eligible Members
(A)	(1) MassHealth Members. The Division covers orthotic and pedorthic services only when
provided to eligible MassHealth members, subject to the restrictions and limitations in the
Division’s regulations. 130 CMR 450.105 specifically states, for each coverage type, which
services are covered and which members are eligible to receive those services.
 (2)	Age Limitations. In addition to any other restrictions and limitations set forth in 130 CMR 442.000 and 450.000, the Division covers orthotic and pedorthic services only when provided to eligible MassHealth members under age 21. This age restriction does not apply to therapeutic, moldable, or custom-molded shoes and shoe inserts for members who have severe diabetic foot disease.
 (3)	Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106.
(B)	For information on verifying member eligibility and coverage type, see 130 CMR 450.107.
442.404:  Provider Eligibility
For services described in 130 CMR 442.000 the Division pays only those providers of orthotic and pedorthic services who are participating in MassHealth as of the date of service.
(A) In State. To participate in MassHealth, a provider with a service facility in Massachusetts must:
 (1)	(a) primarily engage in the business of providing orthotic, pedorthic, and repair services to the public; and (b) meet all state and local requirements for engaging in such business;
 (2)	(a) for orthotic providers, be or employ an orthotist currently certified by the American Board for Certification in Orthotics and Prosthetics, Inc. or the Board for Orthotics/ Prosthetics Certification; or
(b) for pedorthic providers, be or employ a pedorthist currently certified by the Board for Certification in Pedorthics;

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
ORTHOTICS MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 442.000)	PAGE
4-4	

	TRANSMITTAL LETTER
ORT-15	DATE
01/01/03	
 (3)	be a Medicare provider;
 (4)	have a service facility that is physically accessible to MassHealth members during reasonable business hours;
 (5)	maintain a visible sign identifying the business and hours of operation; and
 (6)	maintain a primary business telephone listed under the name of the business in a local directory. The exclusive use of a pager, answering machine, or cell phone is prohibited.
(B) Out of State. A provider with no service facility in Massachusetts may participate in MassHealth only if the provider participates in the medical assistance program of the state in which the provider primarily conducts business and otherwise meets the requirements of 130 CMR 442.404(A). Such a provider may receive payment for MassHealth services only as set forth in 130 CMR 450.109.
442.405: Provider Responsibility
(A)	The provider must ensure that all orthotic and pedorthic equipment and supplies are:
 (1)	clean (sterilized when appropriate);
 (2)	in proper working condition;
 (3)	functional;
 (4)	free from defects; and
 (5)	new and unused at the time of purchase. .

 (B)	The provider must ensure that all orthotic and pedorthic services are the most cost effective, given the medical need for which they are prescribed and the member's physical limitations.
 (C)	The provider must make a reasonable effort to purchase the item from the least costly reliable source by comparing prices charged by different suppliers for comparable items.
442.406:  Covered Services
The Division pays for only those orthotic and pedorthic services listed in Subchapter 6 of the Orthotics Manual.
442.407: Service Limitations
(A) Nonstandard Size. A provider may bill an additional charge for a nonstandard size for off-the-shelf, medical-grade orthopedic shoes once per pair.
(B) Split-Size Charge. A provider may bill a split-size charge for off-the-shelf, medical-grade orthopedic shoes once per pair.