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The MassHealth Prescription for Transportation Form, often referred to simply as the Pt 1 form, plays a crucial role in ensuring that eligible members receive the necessary transportation for their medical appointments. This detailed application is designed for individuals who may require special transportation services due to medical conditions or situations where public transit is insufficient or unavailable. To initiate the process, members or their authorized representatives must provide key personal information, including their name, date of birth, and member ID, along with home and optional alternate addresses. Additionally, essential details of the treating provider, such as their name and contact information, are required, underscoring the collaborative nature of this form. The Pt 1 form outlines the types of treatments needed, the frequency of those treatments, and why transportation services are crucial. It also allows for specific requests, such as wheelchair van service or the need for an escort, affirming the form's focus on accommodating the unique needs of each MassHealth member. Proper completion of the Pt 1 form is vital for swift processing, as it must be signed by a qualified medical provider, ensuring that all the provided information is accurate and justifiable. The importance of this form cannot be overstated; it connects members with necessary resources, affording them access to quality health care in a convenient manner.

Pt 1 Example

COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

OFFICE OF MEDICAID

600 Washington Street Boston, MA 02111 www.mass.gov/masshealth

MassHealth

All Provider Bulletin 192

May 2009

To: All Providers Participating in MassHealth

From: Tom Dehner, Medicaid Director

RE:

Revised Prescription for Transportation (PT-1) Form

 

 

 

 

Background

Changes to the PT-1 Form

Using the New PT-1 Form

As part of preparation for NewMMIS implementation on May 26, 2009, the prescription for transportation (PT-1) form used by providers on behalf of members to request authorization for transportation to a medical appointment, has been revised. A few changes have been made to the form to reflect updates to the MassHealth transportation regulations.

The following changes have been made to the PT-1 form.

•Recipient ID is now called member ID, and is 12 characters long instead of 10.

•The provider number is now MassHealth provider ID/service location, and the NPI field is also included.

•Alternate address information is now included in Section 1, along with home and mailing address information.

•Dental third-party administrator has been added to Section 8 as an authorized signature that MassHealth will accept on the form.

The form continues to be fillable online. We encourage you to submit your PT-1 requests electronically instead of using the fax or mail.

You can start using the revised PT-1 form immediately.

(continued on next page)

MassHealth

All Provider Bulletin 192

May 2009

Page 2

Requesting a Supply of You can request a supply of the PT-1 form online at

the PT-1 Form

www.mass.gov/masshealth. Click on Order Provider Publications in

 

the Online Services box.

 

You can also mail or fax a written request for supplies of this form at

 

the address or fax number below.

 

MassHealth

 

ATTN: Forms Distribution

 

P.O. Box 9118

 

Hingham, MA 02043

 

Fax: 617-988-8973

 

Attached is a sample of the revised PT-1 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.

 

 

 

 

Return completed form to: MassHealth Transportation Unit, P.O. Box 45, Boston, MA 02112-0045, or fax it to 617-988-2925.

PRESCRIPTION FOR TRANSPORTATION FORM

Commonwealth of Massachusetts • EOHHS

Please indicate the type of request:

New form

Renewal

Increase in visits

Alternate pick-up address

www.mass.gov/masshealth

 

 

 

 

 

Please print or type all information.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. MassHealth Member Information

 

 

 

 

 

 

 

Last name

 

 

 

 

 

 

 

 

First name

 

 

Date of birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tel. no.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME ADDRESS (The MassHealth member will be transported to and from this address, unless an alternate pick-up address is listed.)

 

 

Street address

 

 

 

 

 

 

 

 

Apt. no.

City/Town

 

State

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALTERNATE PICK-UP ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street address

 

 

 

 

 

 

 

 

Apt. no.

City/Town

 

State

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS (if different from home address)

 

 

 

 

 

 

 

Street address

 

 

 

 

 

 

 

 

Apt. no.

City/Town

 

State

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.MassHealth Provider Information (Section to be completed by the provider requesting transportation.)

Name of treating provider/facility

 

 

 

 

 

 

 

 

 

 

 

 

 

Tel. no.

 

 

 

 

Ext.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street address

 

 

 

 

 

 

Suite no.

 

City/Town

 

State

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MassHealth provider ID/service location

 

 

 

 

 

 

 

 

 

 

NPI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.Name and Location of Treating Provider/Facility (Indicate where the MassHealth member will be seen.) Check if same as provider listed in Section 2.

Name of treating provider/facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tel. no.

 

Ext.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street address

 

 

 

 

 

 

City/Town

 

 

 

 

 

 

State

Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MassHealth provider ID/service location

 

 

 

 

 

 

 

 

 

 

 

NPI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is the treating facility within the member’s locality (city or town of residence, or adjacent city or town)?

Yes

No

 

 

 

If No, please justify:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Medical Treatment Type

Please list the MassHealth-covered service(s) that the member is receiving at this location.

5. Duration and Frequency of Treatment

How long will the MassHealth member require these services?

 

 

week(s)

 

month(s)

 

 

 

 

 

 

 

 

 

 

 

 

How frequently will the MassHealth member be seen for this service?

 

 

visit(s) per week

 

visit(s) per month

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Why Transportation Services Are Required

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is there a medical reason why the member (or guardian if accompanying a minor) is unable to use public transportation?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, please describe speciic medical reason:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. Other Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is a wheelchair van needed?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is an escort accompanying the member for assistance with ambulation or to accompany a minor?

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Specify other transportation needs:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Provider/Dental TPA Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature:

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

Please check applicable title:

MD

DDS

RNP

RNC

Other (Specify title)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do not write below this line • MassHealth use only

 

 

 

APPROVED. Authorization expires on:

 

 

 

 

 

 

 

 

 

Tracking no.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DENIED. Reason:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MassHealth authorized signature:

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PT-1 (Rev. 05/09)

Instructions for Completing the Prescription for Transportation Form

SECTION 1 – Enter the member’s name, date of birth, MassHealth member ID, telephone number, and home address, including apartment number, if applicable.

In certain circumstances MassHealth may authorize a member to be picked up at an address other than his/ her home address. If the member is to be picked up at an alternate address, enter the alternate address information below the home address information. If there is a mailing address that is different from the home address, enter that below the alternate pick-up address.

SECTION 2 – Enter the provider’s name, telephone number, address, MassHealth provider ID/Service location, and the NPI.

The provider requesting transportation must be a physician, physician’s assistant, nurse midwife, dentist, nurse practitioner, psychologist, or managed-care representative, and an active MassHealth provider.

SECTION 3 – If the provider is also the treating provider, place a checkmark in the box labeled “Check if same as provider listed in Section 2.” If the treating provider is different from the provider illing out Section 2, enter that provider’s name, telephone number, address and, if known, their MassHealth provider ID Service location, and the NPI.

If the treatment destination is outside of the member’s locality (city or town of residence, or immediately adjacent communities), indicate why the medical care is unavailable to the member within the member’s locality.

SECTION 4 – Describe the speciic medical care that will be provided.

SECTION 5 – Indicate how many weeks or months the member will require transportation, and how frequently the member will be going per week or per month for the service. MassHealth will not authorize more than six months of transportation for an acute illness, or one year of transportation for a chronic illness. For a single visit, enter “1” week, and “1” visit per week.

SECTION 6 – Indicate if there is a medical reason that the member (or guardian, in accompanying the member) is unable to use public transportation. Provide the speciic physical or mental disability that prevents the member from using public transportation.

SECTION 7 – Indicate if a wheelchair van or an escort is necessary.

Wheelchair van transportation may be provided for nonemergency medical services for members who use a wheelchair or whose severe mobility impairments prevent them from traveling in a vehicle other than a wheelchair van.

SECTION 8 – The signature of the physician, dental third-party administrator, physician’s assistant, nurse midwife, dentist, nurse practitioner, psychologist, or managed-care representative is required to process the PT-1 form. The signature certiies that the information contained on the form and any attachments, including medical necessity information (per 130 CMR 450.204) is true, accurate, and complete to the best of the signatory’s knowledge. Any falsiication, omission, or concealment of any material fact contained on this form may result in civil penalties or criminal prosecution.

For more detailed information about the MassHealth transportation beneit, consult the MassHealth transportation regulations at 130 CMR 407.000. If you have any questions about completing this form, please call the MassHealth Transportation Authorization Unit at MassHealth Customer Service at 1-800-841-2900.

Get Pt 1 PDF Form

Form Characteristics

Fact Name Description
Form Purpose The MassHealth Prescription for Transportation Form is used to request transportation services for MassHealth members to receive medical care.
Required Information Members must provide personal details such as their name, date of birth, MassHealth ID, and home address to ensure proper transportation arrangements.
Provider Role A licensed healthcare provider must fill out part of the form, indicating their information and confirming the necessity of transportation for the member’s care.
Governing Law This form is regulated under the MassHealth transportation regulations, specifically 130 CMR 407.000, which outlines the process for transportation benefit authorization.

Guidelines on Utilizing Pt 1

Filling out the Pt 1 form is a straightforward process that requires gathering specific information regarding the MassHealth member and their medical provider. Follow the steps below to ensure accurate and complete submission.

  1. Member Information: Enter the member's last name, first name, date of birth, member ID, and telephone number. Then, provide the home address including street address, apartment number, city/town, state, and zip code. If applicable, enter an alternate pick-up address.
  2. Mailing Address: Enter the mailing address if it differs from the home address.
  3. Provider Information: The provider should fill in their name, telephone number, address, MassHealth provider ID, and NPI. Ensure that this provider is an active MassHealth provider.
  4. Treating Provider/Facility: Indicate if the treating provider is the same as the one in Section 2 by checking the appropriate box. If it differs, enter the treating provider's name, telephone number, address, and their MassHealth provider ID and NPI if known.
  5. Locality Confirmation: Specify whether the treating facility is within the member's locality. If it is not, provide justification.
  6. Medical Treatment Type: List the MassHealth-covered services the member is receiving at the location provided.
  7. Duration and Frequency: Specify how long the member will require services in weeks or months. Enter how often the member will visit, noting visits per week or per month.
  8. Transportation Service Need: Indicate if there is a medical reason the member is unable to use public transportation. Provide details if applicable.
  9. Additional Information: Specify whether a wheelchair van or escort is needed, and note any other transportation requirements.
  10. Provider Signature: The provider must sign and date the form. They should check their appropriate title and list it if applicable.

Once the form is completed, it will be submitted for approval by the MassHealth team. The provider or authorized personnel will receive updates regarding the status of the request.

What You Should Know About This Form

What is the Pt 1 form?

The Pt 1 form, officially known as the Massachusetts Prescription for Transportation Form, is used to request transportation services for MassHealth members. This form is essential for obtaining approval for various transportation needs related to medical treatment, ensuring that members can attend necessary appointments without undue hardship.

Who needs to fill out the Pt 1 form?

The form must be completed by the provider requesting transportation for the MassHealth member. This can include a physician, nurse practitioner, psychologist, or dental representative. Accurate information is crucial to facilitate a smooth authorization process.

What information is required in section 1 of the form?

In Section 1, you need to provide personal details about the MassHealth member, including their last name, first name, date of birth, member ID, and telephone number. Additionally, the form requires the member's home address. If applicable, provide an alternate pick-up address and a mailing address, if different from the home address.

How does the provider complete the form?

Providers should complete Section 2 by entering their name, telephone number, address, MassHealth provider ID, and NPI. If the treating provider is different from the provider filling out the form, their information must be entered in Section 3. It's important that this section is filled out correctly to avoid delays in processing.

What details about medical treatment are needed?

Section 4 asks for specific medical services that the MassHealth member is receiving. It is important to list any MassHealth-covered services to justify the need for transportation. Clear and accurate details can support the transportation request effectively.

How is the duration and frequency of treatment described?

In Section 5, you will indicate how long the member will require transportation services, specifying the number of weeks or months. Additionally, include how often the member will need to travel for treatment, detailing the number of visits per week or month. Keep in mind that authorization is typically limited to specific timeframes based on the nature of the illness.

Why is the medical necessity for transportation required?

Section 6 requires you to state whether there is a medical reason that prevents the member from using public transportation. If a medical condition exists, you must cite specific reasons detailing the physical or mental barriers that make public transport impractical or unsafe for the member.

What if special transportation needs exist?

In Section 7, indicate if a wheelchair van is necessary or if an escort will accompany the member. These details help ensure that appropriate transportation methods are utilized and that the member receives the assistance they may require during travel.

What is required at the end of the form?

Section 8 includes a signature line where the appropriate provider must sign and date the form. This signature confirms that all information provided is accurate to the best of their knowledge. The signature is essential for processing and approval by MassHealth.

Who can I contact if I have questions about the form?

If you have any questions about completing the Pt 1 form, reach out to the MassHealth Transportation Authorization Unit at 1-800-841-2900. They can provide guidance and further support for your specific situation.

Common mistakes

Filling out the Pt 1 form can seem straightforward, but mistakes often occur that can delay processing. One common error is omitting essential personal information. Ensure that the MassHealth member's last name, first name, date of birth, and member ID are provided accurately. A small mistake, like a misspelling, could lead to significant delays in transportation requests.

In addition, some applicants fail to double-check their contact information. This includes the telephone number and home address. If any of this information is incorrect, it can hinder communication from MassHealth regarding the status of the request. Inaccurate addresses can also lead to issues with transportation pick-up and drop-off.

An often overlooked part is the alternate pick-up address. Some applicants forget to fill this section out completely, leading to confusion later on. If a different address is needed for pick-up, it must be specified. Leaving it blank can mean that transportation is arranged only to the home address, which may not be suitable.

Moving on, Section 2 requires provider information that is frequently entered incorrectly. Some individuals mistakenly provide incomplete details for the treating provider or facility. This includes missing the provider ID or failing to list the necessary contact information. Accurate details are crucial for authorization and should never be assumed.

In Section 5, it's essential to indicate the duration and frequency of treatment. Many forget to specify either the number of weeks or the frequency of visits. This information helps MassHealth evaluate the need for ongoing transportation services and determine the appropriate authorization period.

Another error involves the justification for needing transportation services. In Section 6, if the answer is "yes" to the medical reason question, provide specific details. Some applicants neglect to include the necessary medical justification, which can lead to denial of the transportation request.

Last but not least, always check that the provider signature and date are completed in Section 8. This is frequently treated as an afterthought. A missing signature can result in the entire form being rejected, requiring the entire process to start over.

Documents used along the form

When completing the MassHealth Prescription for Transportation Form (Pt 1), several other forms and documents may also be necessary to ensure a comprehensive application process. Below is a summary of these additional documents.

  • MassHealth Application Form: This form registers a new member for MassHealth benefits and includes information about household size and income.
  • MassHealth Transportation Authorization Form: Specifically designed for obtaining transportation services, this form outlines the details of the required transport and is essential for scheduling.
  • MassHealth Medical Necessity Form: This document provides justification for the required medical services. It shows why specific services are needed, assisting in the approval process.
  • Physician's Note: A letter or note from the treating physician may be required. It should state the need for transportation and affirm the member's medical condition.
  • Verification of Residency: Proof of residence may be needed to confirm that the member resides within the jurisdiction of MassHealth services.
  • Authorization for Release of Information: This form allows the sharing of the member's medical information among involved parties, ensuring that all necessary information for transport approval is accessible.
  • Emergency Contact Form: It provides details of a person to contact in case of emergencies during transportation or treatment.
  • MassHealth Provider Enrollment Form: If a new provider is involved, this form enrolls them in the MassHealth program and includes their credentials and services offered.

Gathering these documents can streamline the transport request process and improve the chances of obtaining needed services in a timely manner. Proper organization and understanding of each form's purpose are essential for a smooth experience.

Similar forms

The Pt 1 form is crucial for requesting transportation services under MassHealth. Several other documents serve similar purposes in facilitating healthcare access and reporting. Here are four documents that are comparable to the Pt 1 form:

  • Authorization for Medical Services: This document is used to authorize specific medical treatments. Like the Pt 1 form, it requires detailed member information and provider details. Both forms must be filled out completely to ensure that services are approved without delays.
  • Referral Form: A referral form is often required when a patient needs specialized care. Similar to the Pt 1 form, it includes information about the patient and the referring provider. It ensures that the necessary consultations and treatments are approved by a responsible authority.
  • Patient Information Release Form: This document allows for the sharing of a patient's medical information between providers. Both the Pt 1 form and the information release form prioritize patient confidentiality and require signatures to proceed, ensuring that all information shared is authorized.
  • Prior Authorization Request Form: This form seeks prior approval for specific medical procedures or treatments. It resembles the Pt 1 form in that it demands comprehensive details about the patient's medical history and the services requested, thereby reducing potential roadblocks in receiving care.

Dos and Don'ts

When filling out the Pt 1 form for MassHealth, it’s important to follow specific guidelines to ensure your submission is clear and accurate. Here are four things to do and not do:

  • Do print or type all the information clearly. This helps avoid any misunderstandings.
  • Do include all relevant details for the member, including their home address and any alternate addresses.
  • Do specify the medical reason if the member cannot use public transportation. This is crucial for getting the right approval.
  • Do ensure the treating provider's information is complete and accurate. It should match the member's service needs.
  • Don't skip any sections; every piece of information is important for processing the request.
  • Don't forget to sign the form. An unsigned form will lead to delays in approval.
  • Don't use abbreviations or unclear language. Clarity is essential.
  • Don't provide incorrect information. Double-check names, dates, and addresses to ensure everything is accurate.

Misconceptions

There are several common misconceptions about the Pt 1 form used for requesting transportation services through MassHealth. Understanding these misconceptions can help ensure the process goes smoothly.

  • Misconception 1: The Pt 1 form can be submitted by anyone.

    • In reality, only specific providers can submit this form. These may include physicians, nurse practitioners, and other healthcare professionals who are part of the MassHealth program. Ensure the person submitting the form is an authorized provider.

  • Misconception 2: Any address can be used for transportation pick-up.

    • This is not correct. The_pt_1_form primarily allows for the member's home address to be used as the transportation origin. If an alternate address is necessary, it must also be provided, but it typically needs to be justified in specific circumstances.

  • Misconception 3: Public transportation can always be used instead of non-emergency medical transportation.

    • It is important to note that if a member has medical conditions that prevent them from using public transportation, this must be documented on the form. Simply preferring not to use public transport does not qualify for transportation services.

  • Misconception 4: There is no limit to how long transportation can be authorized.

    • This is incorrect. The authorization for transportation through the Pt 1 form has specific time limits based on the medical condition. For acute illnesses, MassHealth may only authorize up to six months of transportation, while for chronic conditions, it can extend to one year.

  • Misconception 5: The provider's signature is optional for the form to be processed.

    • This is a significant misunderstanding. A valid signature from an authorized provider is essential for the processing of the Pt 1 form. This signature indicates that the provider confirms the accuracy of the information present in the application.

Key takeaways

Using the Pt 1 form requires careful attention to detail. Here are some crucial points to remember:

  • Completeness is Key: Ensure all sections are filled out accurately to avoid delays.
  • Member Information: Start with the MassHealth member’s basic details, including full name and address.
  • Provider Details: The provider’s information must be accurate. This section is vital for processing the request.
  • Medical Need: Clearly state any medical reasons that make public transportation impossible for the member.
  • Duration and Frequency: Specify how long transportation will be needed, along with how often the member will require it.
  • Transport Type: Indicate if special transportation needs, like a wheelchair van, are necessary.
  • Signature Required: The form must be signed by an authorized provider. This validates the request.
  • Check for Notification: After submitting, keep an eye out for approval or denial notifications from MassHealth.

Understanding these key aspects will help ensure that the transportation needs are adequately met without unnecessary obstacles.

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