Clinical Assessment and Prior Authorization

(A) Clinical Assessment. As part of the prior authorization process, members seeking ADH must undergo a clinical assessment to assess the member’s clinical status and need for ADH. Completed clinical assessment documentation must be submitted to the MassHealth agency or its designee in the form and format requested by the MassHealth agency. A new clinical assessment is required annually and upon significant change. (B) Prior Authorization. (1) As a prerequisite for payment of ADH, the ADH provider must obtain prior authorization from the MassHealth agency or its designee before the first date of service delivery and annually thereafter, or upon significant change. (2) Prior authorization determines the medical necessity for ADH services as described under 130 CMR 404.405 and in accordance with 130 CMR 450.204: Medical Necessity. (3) Prior authorization may specify the level of payment for ADH (as described under 130 CMR 404.414(D). (4) Prior authorization does not establish or waive any other prerequisites for payment such as the member’s financial eligibility described in 130 CMR 503.007: Potential Sources of Health Care and 517.008: Potential Sources of Health Care. (5) When submitting a request for prior authorization for payment of ADH to the MassHealth agency or its designee, the ADH provider must submit requests in the form and format as required by MassHealth. The ADH provider must include all required information, including, but not limited to, documentation of the completed clinical assessment conducted by the MassHealth agency or its designee; other nursing, medical or psychosocial evaluations or assessments; and any other documentation that the MassHealth agency or its designee requests in order to complete its review and determination of prior authorization. (6) In making its prior authorization determination, the MassHealth agency or its designee, may require additional assessments. (C) Notice of Determination of Prior Authorization. (1) Notice of Approval. If the MassHealth agency or its designee approves a request for prior authorization, it will send written notice to the member and the ADH provider. (2) Notice of Denial or Service Modification. If MassHealth or its designee denies, or approves with a service modification, a request for prior authorization of ADH, the MassHealth agency or its designee will notify both the member and the ADH provider. The notice will state the reason for the denial or service modification and contain information about the member’s right to appeal and the appeal procedure. (3) Right of Appeal. A member may appeal a service denial or modification by requesting a fair hearing in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules. (D) Review Requirement. The MassHealth agency or its designee may at any time review prior authorization of MassHealth members including, but not limited to, instances in which there has been a significant change in the member’s status as defined in 130 CMR 404.402. (130 CMR 404.407 through 404.409 Reserved)