Related to:
Prior Authorization for MassHealth Providers

Medical Necessity Review Forms

skip table of contents

In this list

Absorbent Products

Medical Necessity Review Form for Absorbent Products (PDF 748.87 KB)
Medical Necessity Review Form for Absorbent Products (DOC 54 KB)

Ambulatory Infusion (Insulin Pumps)

Medical Necessity Review Form for Ambulatory Infusion (Insulin Pumps) (DOC 34.5 KB)
Medical Necessity Review Form for Ambulatory Infusion (Insulin Pumps) (PDF 126.9 KB)

Enteral Nutrition Products

Medical Necessity Review Form for Enteral Nutrition Products (DOC 53.5 KB)
Medical Necessity Review Form for Enteral Nutrition Products (PDF 120.27 KB)

Gait Trainers

Medical Necessity Review Form for Gait Trainers (DOC 139 KB)
Medical Necessity Review Form for Gait Trainers (PDF 86.36 KB)

Hospital Beds

Medical Necessity Review Form for Hospital Beds (DOC 62.5 KB)
Medical Necessity Review Form for Hospital Beds (PDF 193.28 KB)

Support Surfaces

Medical Necessity Review Form for Support Surfaces (DOC 32.5 KB)
Medical Necessity Review Form for Support Surfaces (PDF 152.52 KB)

Therapy Services

Request and Justification for Therapy Services [THP-2] (DOC 34 KB)
Request and Justification for Therapy Services [THP-2] (PDF 85.53 KB)
Did you find the information you were looking for on this page? *
We use your feedback to help us improve this site but we are not able to respond directly. Please do not include personal or contact information. If you need a response, please locate contact information elsewhere on this page or in the footer.
Tell us what you think