Prior Authorization

(A) For certain services specified in 130 CMR 402.426 through 402.434, the MassHealth agency requires that the provider of the service obtain prior authorization as a prerequisite to payment. In addition, services that are designated in Subchapter 6 of the Vision Care Manual with the abbreviation “P.A.” require prior authorization. These services include but are not limited to the following: (1) certain contact lenses; (2) low-vision aids; (3) unlisted services; (4) high-index lenses; (5) special-needs glasses; (6) polycarbonate lenses for members aged 21 years of age or older, except for members who are amblyopic or monocular; and (7) vision training. (B) All prior-authorization requests must be submitted in accordance with the instructions in Subchapter 5 of the Vision Care Manual. Prior authorization determines only the medical necessity of the authorized service and does not establish or waive any other prerequisites for payment such as member eligibility or resort to health insurance payment.