Get Masshealth Enteral Form

Filling out the Masshealth Enteral Form can be straightforward with the right guidance. This guide provides step-by-step instructions to help users complete the form accurately and efficiently to ensure their requests for enteral nutrition products are fulfilled.

Follow the steps to successfully complete the Masshealth Enteral Form.

1. Click ‘Get Form’ button to obtain the Masshealth Enteral Form and open it for editing.
2. In Section 1, enter the member’s name, address, MassHealth ID number, date of birth, gender, and both primary and secondary ICD codes.
3. Proceed to Section 2 to input the prescribing provider’s name, address, telephone number, and NPI.
4. In Section 3, fill in the name of the provider of DME along with their address, telephone number, and NPI.
5. In Section 4, check the items requested and enter the corresponding HCPCS codes, modifiers, and a description for each item.
6. For Section 4A, if applicable, the prescribing provider must enter the number of calories needed per day and units of product requested, along with the expected length of need.
7. Section 5 requires the provider of DME to attest with their signature and the date the form was completed.
8. Move to Section 6 where the prescribing provider must fill out the medical justification details, including anthropometric measures and laboratory tests, and attach any pertinent information.
9. Lastly, complete Section 7 with the prescribing provider’s signature and date, ensuring all necessary credentials are checked.
10. Once all sections are completed, save the changes made to the form. You can then download, print, or share the form as needed.

Complete your Masshealth Enteral Form online today for a seamless submission process.