Prior Authorization

(A) Prior Authorization. The DME provider must obtain prior authorization from the MassHealth agency or its designee as a prerequisite for payment of DME identified in the DME and Oxygen Payment and Coverage Guideline Tool or other guidance specified by the MassHealth agency or its designee as requiring prior authorization, or pursuant to 130 CMR 409.413(B), for service codes not listed in Subchapter 6 or in the DME and Oxygen Payment and Coverage Guideline Tool. (B) Prior Authorization for MassHealth Covered Services. Prior authorization for MassHealth covered services is a determination of medical necessity only and does not establish or waive any other prerequisites for payment, such as member eligibility or requirements to seek payment from other liable parties, including Medicare. (C) Documentation of Medical Necessity. Prior authorization requests submitted by the provider for DME must include (1) a completed MassHealth Prior Authorization Request (PA-1) form (if request is submitted on paper); (2) a prescription or letter of medical necessity that meets the requirements of 130 CMR 409.416, including any additional documentation as required by 42 CFR 440.70 or other state or federal law; and (3) if diagnostic test results are used as a means to document medical necessity, the test results must be interpreted, signed, and dated by a physician, or include documentation that supports the need for DME from an appropriate health care professional other than the DME provider, including, but not limited to, physical therapists, speech language pathologists, nurses, respiratory therapists, and occupational therapists who have expertise in the applicable area. (D) Documentation for Prior Authorization Items Requiring Individual Consideration (IC) or Adjusted Acquisition Cost (AAC). For DME that is identified in the DME and Oxygen Payment and Coverage Guideline Tool or in other guidance issued by the MassHealth agency or its designee as requiring IC or AAC, a copy of the original invoice that reflects the provider’s adjusted acquisition costs as set forth in 101 CMR 322.00: Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment. (1) The MassHealth agency will accept a quote from a MassHealth provider for an item that does not have a rate established by EOHHS if the equipment has not been purchased by the provider at the time of the prior authorization request, and when the item being purchased is not an item that the provider normally purchases for its scope of business. The quote must be on the manufacturer’s letterhead or form and must be addressed to the provider. (2) At the time of a claim submission for items requiring a one-time claim submission, or, at initial claim submission for the authorized period for recurring (monthly) claims, the provider must attach the actual manufacturer’s invoice and quote used for MassHealth PA purposes. The provider must keep a copy of the quote and the invoice on file. The MassHealth agency reserves the right to deny claims if a claim is submitted without the appropriate documentation attached. (3) For disposable medical supplies, the invoice must be dated within six months of the prior authorization request. (4) The MassHealth agency will not accept a printed invoice or order from a manufacturer’s website. (E) 90-day Requirement for Submission of Prior Authorization Requests. The provider must submit the request for prior authorization to the MassHealth agency no later than 90 calendar days from the date of the prescription. Failure to submit the request within the 90-day period will result in a denial of the prior authorization request. (F) Prior Authorization Requests for DME Units in Excess of the Maximum Allowable Units. The MassHealth agency requires prior authorization for certain DME provided to the member if the number of units requested exceeds the maximum units described in the DME and Oxygen Payment and Coverage Guideline Tool or in other guidance issued by the MassHealth agency or its designee. (1) The provider must include documentation that supports the medical necessity of the additional units, including requirements under 130 CMR 409.417 and 409.418. (2) If the PA request is authorized by the MassHealth agency, or its designee, the provider must submit a separate claim with a different date of service other than the date of service for the initial maximum number of units and only for the number of excess units actually provided to the member. (G) Additional Assessments or Other Information. 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. (H) Prior Authorization Requests for Members Who Have Other Insurance. For members for whom MassHealth is not the primary insurer, a provider must make diligent efforts to first identify and obtain payment from all other liable parties, including Medicare, before seeking payment from MassHealth in accordance with 130 CMR 450.316: Third-party Liability: Requirements. The MassHealth agency, or its designee, may request documentation of a provider’s diligent efforts to collect payment from Medicare or other liable parties, including documentation of compliance with Medicare's billing and authorization requirements. If documentation requested by the MassHealth agency, or its designee, is not received within the timeframe specified by the MassHealth agency or its designee, or the documentation is incomplete or does not support coverage by MassHealth, the associated claims will be denied. (I) Prior Authorization for Repairs of Durable Medical Equipment. Providers must submit a prior authorization request for repairs, including repairs of a member’s serviceable backup power wheelchair, in accordance with 130 CMR 409.420. (J) Notice of Approval, Denial, or Modification of a Standard or Expedited Prior-authorization Request (1) The MassHealth agency or its designee acts on prior authorization requests in accordance with 130 CMR 450.303: Prior Authorization. (2) Notice of Approval. If the MassHealth agency or its designee approves a prior authorization request for DME, the MassHealth agency will send notice of its decision to the member and the DME provider, within the timeframe specified at 130 CMR 450.303: Prior Authorization. (3) Notice of Denial or Modification. If the MassHealth agency or its designee denies or approves with a modification a prior authorization request for DME, the MassHealth agency or its designee will notify the member and the DME provider, within the timeframe specified at 130 CMR 450.303: Prior Authorization. The notice will state the reason for the denial or modification and will inform the member of the right to appeal and of the appeal procedure in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules. (4) 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. (5) Notice of Deferral. If the MassHealth agency or its designee defers a prior authorization request due to an incomplete submission or lack of documentation to support medical necessity, the MassHealth agency or its designee will notify the member and the DME provider of the deferral and the reason for the deferral and will give the provider an opportunity to submit the incomplete or missing documentation. If the provider does not submit the required information within the timeframe specified at 130 CMR 450.303: Prior Authorization, the MassHealth agency or its designee will make a decision on the prior authorization request using all documentation and forms submitted to the MassHealth agency and will send notice of its decision to the provider and the member in accordance with 130 CMR 409.418(J).