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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyMassachusetts EOHHS DME Prior Auth Update | OpenPa…
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    CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

    Durable Medical Equipment Bulletin 36: New Rates for Durable Medical Equipment

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    This bulletin governs reimbursement rates, product quality specifications, and prior authorization procedures for absorbent durable medical equipment supplied to MassHealth members and applies to participating MassHealth DME providers.

    Policy Summary
    PayerMassachusetts Executive Office of Health and Human Services
    PolicyDurable Medical Equipment Bulletin 36: New Rates for Durable Medical Equipment
    Policy CodePolicy N/A
    Change TypeNew rates, quality specifications, and prior authorization requirements
    Effective DateFebruary 1, 2024
    Next Review DateN/A
    Key ActionSubmit a prior authorization request for all absorbent products with medical-necessity documentation and a signed prescription or letter of medical necessity.
    SourceLink
    POLICY UPDATE CHANGES

    EOHHS established differential rates for certain DME incontinence products under a preferred supplier agreement.

    The bulletin added minimum quality specifications for specified briefs, diapers, protective underwear, and pull-ons.

    The bulletin specifies prior authorization documentation and submission requirements for absorbent products.

    The bulletin provides procedures for requesting increased units, size changes, and extensions of existing prior authorizations.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    12HCPCS codes exempt from NAFC specifications
    7Brief/diaper codes with minimum specifications
    8Protective underwear/pull-on codes with specifications
    90 daysMaximum PA extension
    AllProducts requiring PA

    Product Specifications and Prior Authorization

    Minimum and Universal Product Specifications

    Products must meet the applicable minimum and universal specifications below. Briefs/diapers are subject to the briefs/diapers specifications; protective underwear/pull-ons are subject to both the universal specifications and, unless otherwise noted, the protective underwear/pull-ons minimum specifications.

    Minimum specifications for briefs/diapers

    • No plastic (non-breathable) backing.
    • Rewet rate of <1.0 grams.
    • Rate of acquisition (ROA) of <50 seconds.
    • Retention capacity of >400 grams.
    • Breathable zones with a minimum value of >100 cubic feet per minute (cfm).
    • A closure system that allows for multiple fastening and unfastening occurrences.
    • Applies to HCPCS codes T4521 (adult small), T4522 (adult medium), T4523 (adult large), T4524 (adult extra-large), T4533 (youth), T4543 (bariatric), and T4543-UD (bariatric size XXXL and above).

    Minimum specifications for protective underwear/pull-ons

    • Rewet rate of <1.0 grams.
    • Rate of acquisition (ROA) of <45 seconds.
    • Retention capacity of >250 grams.
    • Breathable (permeability) zones with a minimum value of >100 cubic feet per minute (cfm).

    Universal specifications for all protective underwear and pull-ons

    • Designed with a continuous elasticized waistband and side panels.
    • Designed with multi-elastic leg gathers with >100% elastic tension.
    • Backing is waterproof.

    Protective underwear/pull-on codes and applicable specifications

    • The minimum and universal specifications apply to T4525 (adult small), T4526 (adult medium), T4527 (adult large), T4528 (adult extra-large), T4534 (youth), and T4544 (adult above extra-large).
    • T4531 (pediatric small/medium) and T4532 (pediatric large) are subject only to the universal product specifications; the protective underwear/pull-ons minimum specifications do not apply to these codes.

    Prior Authorization and Medical Necessity

    All absorbent products require prior authorization. MassHealth reviews PA requests, including requests for increased units and size changes, based on medical necessity.

    Initial prior authorization requirements

    • A PA request is required for all absorbent products.
    • The PA request must include clinical documentation supporting medical necessity for the absorbent product(s) requested.
    • The PA request must be submitted to MassHealth in accordance with 130 CMR 409.418, Prior Authorization.
    • The DME provider must obtain a written prescription or letter of medical necessity (LMN) signed by the member’s prescribing provider. The prescription or LMN must meet 130 CMR 409.416, Requirements for Prescriptions or Letters of Medical Necessity Completed by the Ordering Practitioner.
    • Any additional clinical documentation supporting medical necessity must be submitted with the PA request.

    Covered Product Codes and Quality Thresholds

    Covered products exempt from NAFC specificationsHCPCSCovered
    T4529Covered product not subject to NAFC minimum product specifications
    T4530Covered product not subject to NAFC minimum product specifications
    T4531Covered product not subject to NAFC minimum product specifications
    T4532Covered product not subject to NAFC minimum product specifications
    T4535-UDCovered product not subject to NAFC minimum product specifications
    T4535Covered product not subject to NAFC minimum product specifications
    T4536Covered product not subject to NAFC minimum product specifications
    T4537Covered product not subject to NAFC minimum product specifications
    T4539Covered product not subject to NAFC minimum product specifications
    T4540Covered product not subject to NAFC minimum product specifications
    1–10 of 12
    1/2
    Briefs and diapers subject to minimum specificationsHCPCSCovered
    T4521Adult sized disposable incontinence product, brief/diaper, small size, each
    T4522Adult sized disposable incontinence product, brief/diaper, medium size, each
    T4523Adult sized disposable incontinence product, brief/diaper, large size, each
    T4524Adult sized disposable incontinence product, brief/diaper, extra-large size, each
    T4533Youth sized disposable incontinence product, brief/diaper, each
    T4543Disposable incontinence product, brief/diaper, bariatric, each
    T4543-UDDisposable incontinence product, brief/diaper, bariatric, size XXXL and above, each
    Protective underwear and pull-ons subject to product specificationsHCPCSCovered
    T4525Adult sized disposable incontinence product, protective underwear/pull-on, small size, each
    T4526Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each
    T4527Adult sized disposable incontinence product, protective underwear/pull-on, large size, each
    T4528Adult sized disposable incontinence product, protective underwear/pull-on, extra-large size, each
    T4534Youth sized disposable incontinence product, protective underwear/pull-on, each
    T4544Adult sized disposable incontinence product, protective underwear/pull-on, above extra-large, each
    T4531Pediatric sized disposable incontinence product, protective underwear/pull-on, small/medium size, each
    T4532Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each
    Brief/diaper rewet rate
    Product categoryBriefs and diapers
    Quality measureRewet rate
    Required threshold<1.0 grams
    Brief/diaper rate of acquisition
    Product categoryBriefs and diapers
    Quality measureRate of acquisition (ROA)
    Required threshold

    Prior Authorization Submission Requirements

    Prior Authorization

    Submit PA and medical-necessity documentation

    All absorbent products require prior authorization. Submit clinical documentation supporting medical necessity, along with a written prescription or letter of medical necessity signed by the member’s prescribing provider and any additional supporting clinical documentation.

    • The PA request must be submitted to MassHealth in accordance with 130 CMR 409.418.
    • The prescription or letter of medical necessity must meet the requirements of 130 CMR 409.416.
    Billing Rule

    Submit PA requests electronically

    Submit PA requests electronically through the MassHealth LTSS Provider Portal or LTMS. An approved electronic claims waiver or specified pharmacy-billing exceptions may apply.

    Key Terms

    Preferred supplier agreement
    AgreementPreferred supplier agreement between a manufacturer and a governmental unit or units
    Established byExecutive Office of Health and Human Services (EOHHS)
    PurposeEstablishes differential reimbursement rates for covered durable medical equipment or medical supplies
    NAFC standards
    TermNAFC standards
    Applies toSpecified briefs, diapers, protective underwear, and pull-ons
    DefinitionProduct quality standards for the covered incontinence products
    Policy Summary
    PayerMassachusetts Executive Office of Health and Human Services
    PolicyDurable Medical Equipment Bulletin 36: New Rates for Durable Medical Equipment
    Policy CodePolicy N/A
    Change TypeNew rates, quality specifications, and prior authorization requirements
    Effective DateFebruary 1, 2024
    Next Review DateN/A
    Key ActionSubmit a prior authorization request for all absorbent products with medical-necessity documentation and a signed prescription or letter of medical necessity.
    SourceLink
    On This Page
    Product Specifications and Prior AuthorizationCovered Product Codes and Quality ThresholdsPrior Authorization Submission RequirementsKey Terms

    PA submission method

    • Providers must submit PA requests electronically through the MassHealth Long Term Services and Supports (LTSS) Provider Portal at www.masshealthltss.com.

    • Electronic-submission exceptions

      • The provider has a currently approved electronic claims waiver.
      • The PA request is for prescription drugs, regardless of where they are dispensed or how they are billed.
      • The PA request is for non-drug products dispensed at a pharmacy and billed through the Pharmacy Online Processing System (POPS) or the Medicaid Management Information System (MMIS).
    • For paper PA requests, MassHealth encourages providers to use the MassHealth Prescription and Medical Necessity Review Form for Absorbent Products (MNR-AP).

    Changes during an existing PA

    • For an increase in units for approved products during the period covered by an existing PA, the provider must submit a new PA request with updated documents supporting medical necessity. MassHealth will adjust the member’s PAs to ensure that the same HCPCS code is not active on multiple PAs.
    • For a change in size, the provider must submit a new PA request. Because medical necessity has been established for the specific product category on the existing PA, additional documents are not required for a size change within the same product category.
    • A size-change request must state in the external text message or provider comment section that the member requires a change in size, and must include the active PA number, requested size, and corresponding HCPCS code.
    • The existing PA will be modified to reflect an approved size change, and notices will be sent to the DME provider and MassHealth member regarding the MassHealth decision.
    • MassHealth reviews all requests for PA, including requests for an increase in products or a change in size, based on medical necessity.

    PA extensions

    • A provider may request an extension of a PA for up to 90 days to ensure continued service for a member when the provider has not been able to obtain documentation needed for a new PA from the member’s medical provider.up to 90 days
    • The provider must file a new PA request and state in the external text message or provider comment section the reason for the extension, length of extension requested, and PA number requiring extension.
    • Providers are expected to obtain appropriate documentation in a timely manner and maintain records of outreach to members and their prescribers.
    • All documentation, recordkeeping, and other applicable provisions of 130 CMR 450.000, Administrative and Billing Regulations, and 130 CMR 409.000, Durable Medical Equipment Services, apply.
    <50 seconds
    Brief/diaper retention capacity
    Product categoryBriefs and diapers
    Quality measureRetention capacity
    Required threshold>400 grams
    Breathable-zone permeability
    Applicable productsBriefs, diapers, protective underwear, and pull-ons
    Quality measureBreathable-zone permeability
    Required threshold>100 cubic feet per minute (cfm)
    Protective underwear/pull-on rewet rate
    Product categoryProtective underwear and pull-ons
    Quality measureRewet rate
    Required threshold<1.0 grams
    Protective underwear/pull-on rate of acquisition
    Product categoryProtective underwear and pull-ons
    Quality measureRate of acquisition (ROA)
    Required threshold<45 seconds
    Protective underwear/pull-on retention capacity
    Product categoryProtective underwear and pull-ons
    Quality measureRetention capacity
    Required threshold>250 grams
    • Exceptions include prescription drugs and non-drug products dispensed at a pharmacy and billed through POPS or MMIS.
    • MassHealth encourages providers using paper PA requests to use the Prescription and Medical Necessity Review Form for Absorbent Products.
    Documentation Required

    File a new PA for unit or size changes

    For an increase in units during an existing PA period, submit a new PA request with updated documents supporting medical necessity. For a size change, submit a new PA request identifying the need for the change, active PA number, requested size, and corresponding HCPCS code; additional documents are not required for a size change within the same product category.

    • MassHealth reviews requests for increased products or size changes based on medical necessity.
    • The existing PA will be modified to reflect an approved size change.
    Prior Authorization

    Request PA extensions before coverage ends

    Providers may request a PA extension of up to 90 days to ensure continued service, including when documentation needed for a new PA has not yet been obtained. File a new PA request stating the reason for the extension, requested extension length, and PA number requiring extension.

    • Providers are expected to obtain the appropriate documentation in a timely manner and maintain records of outreach to members and prescribers.
    Billing Rule

    Submit CCM member PAs through POSC

    For Community Case Management members, submit all information related to the PA request through the Provider Online Service Center (POSC), unless an approved electronic claims waiver or specified pharmacy-billing exception applies.

    • For PA requirements, service limits, modifiers, and allowable place-of-service codes, refer to the MassHealth Durable Medical Equipment and Oxygen Payment and Coverage Guideline Tool.
    • Providers may contact the MassHealth Customer Service Center at (800) 841-2900 with questions about POSC access.
    Letter of medical necessity
    DocumentWritten prescription or letter of medical necessity (LMN)
    SignerMember’s prescribing provider
    PurposeSupports the medical necessity of the requested absorbent product(s)