Payment for any service listed in 130 CMR 427.000 is conditioned upon its full and complete documentation in the recipient’s medical record. In addition to fulfilling all the recordkeeping requirements of 130 CMR 450.205, the provider must keep a record of all oxygen and respiratory therapy equipment and repair services furnished to a recipient for at least four years following the date of service. This record must include the following:

1. (A) a prescription for all rentals and purchases that fulfills the requirements of 130 CMR 427.408;
2. (B) a copy of the approved prior-authorization request for all equipment, supplies, or services requiring prior authorization;

3. (C) an acknowledgment of receipt, including:

   1. (1) the date the equipment was delivered or the service was furnished;
   2. (2) a description of the equipment or service, including the manufacturer’s brand name, model number, and serial number; and
   3. (3) the signature of the recipient or the recipient’s legal representative, acknowledging receipt of the equipment, supplies, or services on that date; and
4. (D) a manufacturer’s invoice or cost report demonstrating the cost to the provider of the materials.

(130 CMR 427.431 through 427.439 Reserved)

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-14

Provider Manual Series (130 CMR 427.000)

Transmittal Letter Date

Oxygen and Respiratory Therapy

Equipment Manual

OXY-35 04/28/23