Clinical Assessment and Prior Authorization

(A) Clinical Assessment. As part of the prior authorization process, members seeking AFC must undergo a clinical assessment to assess the member’s clinical status and need for AFC. Completed clinical assessment documentation must be submitted to MassHealth, 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 AFC, the AFC provider must obtain prior authorization from the MassHealth agency or its designee before the first date of service delivery and annually thereafter, and upon significant change. (2) Prior authorization determines the medical necessity for AFC as described under 130 CMR 408.416 and in accordance with 130 CMR 450.204: Medical Necessity. (3) Prior authorization may specify the service level for payment for the service. (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 130 CMR 517.008: Potential Sources of Health Care. (5) When submitting a request for prior authorization for payment of AFC to the MassHealth agency, or its designee, the AFC provider must submit requests in the form and format as required by the MassHealth agency. The AFC 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 the review and determination of prior authorization. (6) In making its prior authorization determination, the MassHealth agency or its designee, may require additional assessments of the member or require other necessary information in support of the request for prior authorization. (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 AFC provider. (2) Notice of Denial or Service Modification. If the MassHealth agency or its designee denies, or approves with a service modification, request for prior authorization of AFC, the MassHealth agency or its designee will notify both the member and the AFC 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 408.402.