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West Springfield, MA (413) 785-4047 Bloomfield, CT (860) 904-2419

Forms and Insurance Requirements

We understand that the insurance process can be complicated, and we are here to help. This page explains the paperwork requirements for diabetic shoes and inserts. One thing that is always required is a prescription. The prescription must come from your doctor, we cannot write one for you. If you do not already have a prescription, our office can provide you with the details you will need to bring to your physician to obtain a prescription. If you have any questions, please call us at 413-785-4047 or 860-904-2419.

Forms and required medical documentation for your first visit:

    • Required for all patients: A Patient Consent Form
      • This form can be found on the right side of this webpage. It gives us permission to bill your insurance and acknowledges our privacy and financial policy.
      • You may print, complete, and bring this form to your first visit. We also have them available in our office for your convenience.
    • Required for all patients: A prescription for diabetic shoes and/or custom inserts
      • This can come from a primary care, an endocrinologist, a podiatrist, a wound care physician, or another doctor involved in your care.
    • Required for Medicare patients: A recent office note from an MD or DO documenting your diabetic management (we will need this on file prior to scheduling an appointment).
      • Please have this note faxed to our office at 413-785-4048 ATTN: Medical Records.
      • Some practices may require you sign a medical record release prior to sending your office note(s). For your convenience, common medical release forms are listed below. Please select and complete the appropriate form if necessary.

If you do not see your referring facility in the list above, please complete our standard medical release form.
P&O Solutions Medical Record Release  English

Requirements for Diabetic Footwear By Plan Type

For Patients with:

Medicare Part B

If you have Medicare Part B or a Medicare Managed plan, such as Blue Cross Medicare Advantage or Tufts Medicare Preferred, you will need to have the proper paperwork in order to qualify for diabetic footwear. Medicare allows one pair of diabetic shoes and up to three pairs of custom heat molded inserts per calendar year as long as the following criteria are met:

  • The patient has diabetes and one of the following conditions:
    a. Foot deformity
    b. Current or previous foot ulceration
    c. Current or previous pre-ulcerative calluses
    d. Previous partial amputation of one or both feet, or complete amputation of one foot
    e. Poor circulation
  • The patient must have an in-person visit with their primary care physician or endocrinologist with the credentials of MD or DO within six months of receiving diabetic shoes. At this visit it must be documented in the patient’s medical record that they have diabetes and at least one of the conditions mentioned above. The physician must also document any information relating to the patient’s diabetic management within the medical record and that the patient needs diabetic footwear. The following forms must be completed by your physician and forwarded to our office prior to your evaluation appointment:
    PDF Medicare CMN
    PDF Addendum to Medical Records
  • The actual prescription can be written by the patient’s primary care physician, endocrinologist, podiatrist, OR another medical professional. Other professionals could include a physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS). However, the documentation of need must still come from a certifying MD or DO.

MassHealth

If you have a MassHealth plan that covers orthotic and prosthetic services, you may be eligible for one pair of diabetic shoes and three pairs of custom heat molded inserts per year. In order to qualify, the following is required:

  • Both the medical documentation AND the prescription must come from the primary care physician or endocrinologist with the credentials of MD or DO. Unlike Medicare, another professional CANNOT write the prescription.
  • A copy of this form completed by the same MD or DO physician that writes your prescription:
    MassHealth CMN (pdf)

*Please remember: MassHealth Primary Care Clinician Plans (PCC) require a referral from your primary care physician. Please have your doctor’s office submit a referral through the MassHealth provider portal. Our NPI# is 1558376913

Medicare & MassHealth

You must follow the rules for MassHealth requiring you to obtain medical documentation AND a prescription from your primary care physician or endocrinologist with the credentials of MD or DO. Therefore, the following must be completed:

    • In-person visit with your primary care physician or endocrinologist with the credentials of MD or DO within six months of receiving diabetic shoes.
    • MD or DO physician’s notes
    • Prescription from MD or DO physician
    • (PDF) MassHealth CMN
    • (PDF) Medicare CMN
    • (PDF) Addendum to Medical Records

Commonwealth Care Alliance (Senior Care & One Care)

Commonwealth Care Alliance only requires a prescription for diabetic shoes and inserts. The prescription can come from a primary care physician, podiatrist, endocrinologist, wound care physician, nurse practitioner, physicians assistant or any physician involved in the patients care.

Serenity Care PACE

Serenity Care PACE requires a prescription for diabetic shoes and inserts and a referral from Serenity Care PACE. The prescription can come from a primary care physician, podiatrist, endocrinologist, wound care physician, nurse practitioner, physicians assistant or any physician involved in the patients care.

*Please note that Serenity Care PACE must schedule the appointment on your behalf. Please call them directly to request an appointment with us.

Husky Plan (CT Medicaid)

Husky Plan requires a prescription for diabetic shoes and inserts. The prescription can come from a primary care physician, podiatrist, endocrinologist, wound care physician, nurse practitioner, physicians assistant or any physician involved in the patients care. Husky Plans that do cover shoes and inserts only cover 2 pairs of custom or heat molded inserts per year.

*We accept Plans A-D but some levels of coverage don’t cover Durable Medical Equipment, Prosthetics, or Orthotics. We can check your plan for you or you can also call Husky to verify if your plans covers these services.

BMC Healthnet

BMC Healthnet requires a prescription for diabetic shoes and inserts and prior authorization for all Durable Medical Equipment. The prescription can come from a primary care physician, podiatrist, endocrinologist, wound care physician, nurse practitioner, physicians assistant or any physician involved in the patients care.

Allways Health Partners (formally Neighborhood Health Plan)

Allways Health Partners requires a prescription, letter of medical necessity, and prior authorization for all Durable Medical Equipment. This paperwork can come from a podiatrist, primary care physician, endocrinologist, nurse practitioner, physicians assistant or any other clinician involved in the patients care.

Blue Cross Blue Shield Plans

All Blue Cross plans require a doctor’s prescription. Some also require letters of medical necessity and prior authorization for diabetic shoes and inserts. This paperwork can come from a podiatrist, primary care physician, endocrinologist, nurse practitioner, physicians assistant or any other clinician involved in the patients care.

*If you would like to know if your plan type requires a letter of medical necessity please call us at (413)785-4047 or (860)904-2419.

*Blue Cross Medicare Advantage Plans follow the same Medicare paperwork requirements as Medicare Part B. You must have an in-person visit with an MD or DO that treats your diabetic condition within six months of receiving shoes. Please see Medicare Part B for more information.

*The Blue Cross Federal Employee Program does not cover diabetic shoes for any member. They will however cover diabetic inserts. Please call us for more information. 

We also recommend you contact Blue Cross directly to verify your Durable Medical Equipment benefits (DME for short). Ask them if you have a co-insurance amount, and if your deductible applies. You can also give them these possible codes to find out if they are deemed covered, A5500, A5501, A5512, A5513, and A5514.

Tufts Health Plans

All Tufts plans require a doctor’s prescription. Some also require letters of medical necessity and prior authorization for diabetic shoes and inserts. This paperwork can come from a podiatrist, primary care physician, endocrinologist, nurse practitioner, physicians assistant or any other clinician involved in your care.

*Tufts Medicare Preferred Plans follow the same Medicare paperwork requirements as Medicare Part B. You must have an in-person visit with an MD or DO that treats your diabetic condition within six months of receiving shoes. Please see Medicare Part B for more information.

*Tufts Public Plans (formally Network Health) require a prescription, letter of medical necessity and prior authorization for all Durable Medical Equipment.

We also recommend you contact Tufts directly to verify your Durable Medical Equipment benefits (DME for short). Ask them if you have a co-insurance amount, and if your deductible applies. You can also give them these possible codes to find out if they are deemed covered, A5500, A5501, A5512, A5513, and A5514.

Health New England Plans

Health New England Plans (including Medicare Advantage and Be Healthy) require a prescription for diabetic shoes and inserts and prior authorization for all Durable Medical Equipment. The prescription can come from a primary care physician, podiatrist, endocrinologist, wound care physician, nurse practitioner, physicians assistant or any physician involved in the patients care.

Please Note: Health New England provides us with limited benefit information. We highly recommend you contact Health new England directly to verify your Durable Medical Equipment benefits (DME for short). Ask them if you have a co-insurance amount, and if your deductible applies. You can also give them these possible codes to find out if they are deemed covered, A5500, A5501, A5512, A5513, and A5514.

Cigna Health Plans

All Cigna plans require a doctor’s prescription and a letter of medical necessity for diabetic shoes and inserts. Some plans also require prior authorization. This paperwork can come from a podiatrist, primary care physician, endocrinologist, nurse practitioner, physicians assistant or any other clinician involved in the patients care.

We also recommend you contact Cigna directly to verify your Durable Medical Equipment benefits (DME for short). Ask them if you have a co-insurance amount, and if your deductible applies. You can also give them these possible codes to find out if they are deemed covered, A5500, A5501, A5512, A5513, and A5514.

United Health Care & AARP Plans

GIC/Unicare

All GIC/Unicare plans require a doctor’s prescription and a letter of medical necessity for diabetic shoes and inserts. Some plans also require prior authorization. This paperwork can come from a podiatrist, primary care physician, endocrinologist, nurse practitioner, physicians assistant or any other clinician involved in the patients care.

We also recommend you contact GIC or Unicare directly to verify your Durable Medical Equipment benefits (DME for short). Ask them if you have a co-insurance amount, and if your deductible applies. You can also give them these possible codes to find out if they are deemed covered, A5500, A5501, A5512, A5513, and A5514.

Department of Veterans Affairs

We accept patients with Department of Veterans Affairs benefits. You’ll need an Orthotics/Prosthetics referral from your podiatrist or another physician at your VA Medical Center. The VA may ask for our contact information and our NPI# which is: 1558376913.

Other Commercial Insurance Plans

All commercial plans require a doctor’s prescription. Some also require letters of medical necessity and prior authorization for diabetic footwear. Please call us at 413-785-4047 for information about your insurance plan requirements.

You can also call your insurance company and ask about your Durable Medical Equipment benefits (DME for short). Ask them if you have a co-insurance amount, and if your deductible applies. You can also give them these possible codes to find out if they are deemed covered, A5500, A5501, A5512, A5513, and A5514.

For all patients, please consider sharing relevant medical records. Notes from your primary care doctor, podiatrist, or other medical providers will assist our pedorthist in understanding your needs, recommending the best shoe/foot orthotic for you, and providing continuity of care.

Request an appointment for shoes or foot orthotics

Fill out the form below.

Are you an existing patient?* YesNo

Do you have a prescription?* YesNo

Please not we can NOT bill your insurane without a doctor's order

Are you Diabetic?* YesNo

What products/devices are you looking for? (Check all that apply.)*
Diabetic Shoes & Inserts (please only check this item if you are diabetic)Orthopedic Shoes (please check this item if you are not diabetic)Custom molded arch supportsA heel lift for leg length discrepancyOther

Other, please specify

Do you go to Wound Care? If so, which one?

What type of insurance do you have? (Check all that apply.)
MedicareMassHealthHusky PlanBlue CrossHealth New EnglandTuftsUnited Health CareCommonwealth Care AllianceAetnaCignaAARPGIC/UnicareOther

Other, please specify

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