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

Forms and Insurance Requirements

Forms and information required for shoes and foot orthotics are listed below by Insurance. If you have any questions, please call us directly at 413-785-4047 or 860-904-2419.

Paperwork for Diabetic Footwear By Plan Type

For Patients with:

Medicare only

If a patient has Medicare Part B or a Medicare Managed plan, such as Blue Cross Medicare Advantage or Tufts Medicare Preferred, they 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. These Notes can be faxed to our West Springfield or Bloomfield office and must be on file prior to scheduling an appointment. 
    • This same physician must complete the Medicare CMN and Addendum to clinical notes. These two forms can be found on the right hand side of this webpage.
  • The actual prescription can be written by the patient’s primary care physician, endocrinologist, OR another medical professional. Other professionals could include a Doctor of Podiatric Medicine (DPM), 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 only

If a patient has a MassHealth plan that covers orthotic and prosthetic services, they 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:

  • A doctors prescription.
  • A copy of the MassHealth CMN for diabetics completed by an MD or DO physician (this form can be found on the right hand side of this webpage).

Unlike Medicare, MassHealth will cover custom foot orthotics, and shoe modifications such as lifts and rocker bottoms for non diabetic patients if they have the following:

  • A doctors prescription, this can come from an MD, DO, NP, PAC or a DPM.
  • The MassHealth Non Diabetic CMN completed by the same physician (this form can be found on the right hand side of this webpage).

*MassHealth Primary Care Clinician Plans (PCC) require a referral from the primary care physician. Our NPI# is 1558376913, please submit a referral request through the MMIS portal.

Medicare AND MassHealth

If a patient has Medicare Part B or a Medicare Managed plan, such as Blue Cross Medicare Advantage or Tufts Medicare Preferred, and MassHealth secondary they 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. These Notes can be faxed to our West Springfield or Bloomfield office and must be on file prior to scheduling an appointment. 
    • This same physician must complete the Medicare CMN, Addendum to clinical notes and MassHealth Diabetic CMN. These three forms can be found on the right hand side of this webpage.
  • The actual prescription can be written by the patient’s primary care physician, endocrinologist, podiatrist, OR another medical professional. Other professionals could include a Doctor of Podiatric Medicine (DPM), 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.

Commonwealth Care Alliance (One Care & Senior Care)

Commonwealth Care Alliance 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 clinician involved in the patients care.

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 clinician involved in the patients care.

BMC Healthnet (MA Medicaid Plan)

BMC Healthnet 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.

Allways Health Partners (formally Neighborhood Health Plan)

Allways Health Partners requires a prescription and letter of medical necessity 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 clinician involved in the patients care.

Blue Cross Blue Shield Plans

All Blue Cross plans require a doctor’s prescription, some also require a letter of medical necessity 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 the members plan type requires a letter of medical necessity please call us at (413)785-4047 or (860)904-2419.

Tufts Health Plan

Commercial Tufts Health Plans require 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 clinician involved in the patients care.

Tufts Medicare Preferred requires a prescription for diabetic shoes and inserts and all the same paperwork as Medicare Part B. The prescription can come from a primary care physician, podiatrist, endocrinologist, wound care physician, nurse practitioner, physicians assistant or any clinician involved in the patients care. The Medicare documentation  must still come from an MD or DO treating the diabetic condition.

Tufts Health Public Plans  require a prescription and letter of medical necessity 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 clinician involved in the patients care.

United Health Care & AARP Plans

United Health Care and AARP require 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 clinician involved in the patients care.

Medicare Advantage & Senior Care Options Plans require a prescription for diabetic shoes and inserts and all the same paperwork as Medicare Part B. The prescription can come from a primary care physician, podiatrist, endocrinologist, wound care physician, nurse practitioner, physicians assistant or any clinician involved in the patients care. The Medicare documentation  must still come from an MD or DO treating the diabetic condition.

Cigna Plans

Cigna requires a prescription and letter of medical necessity 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 clinician involved in the patients care.

GIC/Unicare

GIC/Unicare requires a prescription and letter of medical necessity 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 clinician involved in the patients care.

Other Commercial Insurance Plans

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

We also recommend patients call their insurance companies and ask about their Durable Medical Equipment benefits (DME for short). They should ask if they have a co-insurance, and if their deductible applies. They can also provide these possible codes to find out if they are deemed covered, A5500, A5501, A5512, A5513, and A5514.

*Notes from a primary care doctor, podiatrist, or other medical providers will assist our pedorthist or orthotist in understanding your patients needs, recommending the best products for them, 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

Additional Comments

Upload any additional documents

MassHealth Primary Care Clinician plans require the members PCP to enter a referral on the MMIS portal. For your convenience our NPI# is 1558376913.

Medicare CMN

Medicare Addendum to Clinical Notes

MassHealth CMN (for non-diabetics only)

Medicare Supplier Standards