Prior Authorization Requirements

(A) General Terms. (1) Prior authorization must be obtained from the MassHealth agency or its designee as a prerequisite to payment after certain limits are reached, as described in 130 CMR 403.410. Without such prior authorization, the MassHealth agency will not pay providers for these services. (2) 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. (3) Approvals for prior authorization specify the number of hours, visits, or units for each service that are medically necessary and payable each calendar week and the duration of the prior authorization period. The authorization is issued in the member’s name and specifies frequency and duration of care for each service approved per calendar week. (4) The home health agency must submit all prior authorization requests in accordance with the MassHealth agency’s administrative and billing regulations and instructions and must submit each such request to the appropriate addresses listed in Appendix A of the Home Health Agency Manual. (5) In conducting prior authorization review, the MassHealth agency or its designee may refer the member for an independent clinical assessment to inform the determination of medical necessity for home health services. (6) If authorized services need to be adjusted because the member’s medical needs have changed, the home health agency must submit an adjustment request to the MassHealth agency or its designee. (7) MassHealth only pays for services up to the amount authorized in the PA. (B) Skilled Nursing and Medication Administration Visits for MassHealth Members Not Enrolled in a Capitated Program. (1) The home health agency must obtain prior authorization for the provision of skilled nursing and medication administration visits beyond the amounts set forth in 130 CMR 403.410(B)(5). See 130 CMR 403.410(C) for prior authorization requirements relative to home health aide services. See 130 CMR 403.410(D) for prior authorization requirements relative to home health therapy services. (2) To obtain prior authorization for skilled nursing and/or medication administration visits, the home health agency must submit to the MassHealth agency or its designee written physician or ordering non-physician practitioner orders that identifies the member’s admitting diagnosis, frequency, and, as applicable, duration of nursing services, and a description of the intended nursing intervention. (3) The home health agency must complete a prior authorization request through the Provider Portal or by using the Request and Justification for Nursing and Home Health Aide Services Form, if paper submission is necessary, in accordance with 130 CMR 403.410(B)(1) and 403.415, as applicable. This must be submitted to the MassHealth agency or its designee for all prior authorization requests for skilled nursing, medication administration, and home health aide services, as applicable. (4) Prior authorization for any and all home health skilled nursing and medication administration visits is required whenever the services provided exceed more than 30 intermittent skilled nursing and/or medication administration visits in a calendar year. (5) Any verbal request for changes in service authorization must be followed up in writing to the MassHealth agency or its designee within two weeks of the date of the verbal request. (C) Home Health Aide Services for MassHealth Members Not Enrolled in a Capitated Program. (1) The home health agency must obtain prior authorization for the provision of home health aide services beyond the amounts set forth in 130 CMR 403.410(C)(5). (2) To obtain prior authorization for home health aide services, the home health agency must submit to the MassHealth agency or its designee written physician or ordering non-physician practitioner orders that identifies the member’s admitting diagnosis, frequency of services, and, as applicable, duration of home health aide services, and a description of the intended interventions. (3) The home health agency must complete a prior authorization request through the Provider Portal or by using the Request and Justification for Nursing and Home Health Aide Services Form, if paper submission is necessary, in accordance with 130 CMR 403.410(C)(1) and 403.416. This must be submitted to the MassHealth agency or its designee with all prior authorization requests for skilled nursing, medication administration visits, therapy, or home health aide services as applicable. (4) Prior authorization for home health aide services is required whenever services provided exceed more than 240 home health aide units in a calendar year. (D) Therapy Services for All Members for Whom Therapies Are a Covered Service. (1) The home health agency must obtain prior authorization from the MassHealth agency or its designee as a prerequisite for MassHealth payment as primary payer of the following services to eligible MassHealth members: (a) more than 20 occupational-therapy or 20 physical-therapy visits, including any initial patient assessment or observation and evaluation or reevaluation visits, for a member within a calendar year; (b) more than 35 speech-language therapy visits, including any initial patient assessment or observation and evaluation or reevaluation visits, for a member within a calendar year; and (c) If a member requires home health aide services in addition to therapy services, prior authorization is required whenever the services provided exceed any of the limits set forth for therapy or home health aide services. The prior authorization request for home health aide services will need to include the request for physical, occupational, or speech/language therapy services. (2) The home health agency must complete a prior authorization request through the Provider Portal or by using the Request and Justification for Therapy and Home Health Aide Services Form, if paper submission is necessary, in accordance with 130 CMR 403.410(D)(1) and 403.417. This form must be submitted to the MassHealth agency or its designee with all prior authorization requests. (E) MassHealth Members Enrolled in a Capitated Program. For those members who are enrolled in a MassHealth-approved capitated program, the home health agency must follow the authorization procedures of the capitated program where applicable for home health services. For those members in a capitated program whose nursing service needs are more than two hours in duration and are not covered by the capitated program, the home health agency must comply with 130 CMR 403.438.