Prior Authorization

(A) For certain outpatient services described in 130 CMR 410.000, the MassHealth agency requires that the hospital outpatient department obtain prior authorization. No payment is made for outpatient services whenever a hospital is required, but fails, to obtain prior authorization from the MassHealth agency or its designee. It is the responsibility of the hospital to obtain the necessary prior authorization. (B) Prior authorization determines only the medical necessity of the authorized service and does not 4. Program Regulations establish or waive any other prerequisites for payment, such as member eligibility or resort to health insurance payment. (C) All requests for prior authorization must be submitted in accordance with the instructions in Subchapter 5 of the Outpatient Hospital Manual. For more information on requests for prior authorization, see 130 CMR 450.303: Prior Authorization. (D) Members enrolled with a MassHealth managed care provider require service authorization before certain behavioral health services are provided. For more information, see 130 CMR 450.124: Behavioral Health Services. (E) The hospital must obtain prior authorization for the following outpatient therapy services: (1) more than 20 occupational therapy visits or 20 physical therapy visits, including group therapy visits, for a member within a 12-month period; and (2) more than 35 speech/language therapy visits, including group therapy visits, for a member within a 12-month period.