Prior Authorization Requirements

(A) Prior authorization must be obtained from the MassHealth agency or its designee as a prerequisite for payment for CSN services and before services are provided to the member. Without such prior authorization, CSN services will not be paid by the MassHealth agency. (B) 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. (C) The MassHealth agency or its designee will conduct the assessment of need for CSN services and coordinate other MassHealth LTSS for the member, as appropriate. When the MassHealth agency or its designee conducts an assessment of need for CSN services and authorizes CSN services for the member, the member will select the independent nurse who will be responsible for providing CSN services. The MassHealth agency or its designee will provide written notification of its assessment to the member, and if applicable, the independent nurse selected by the member. (D) The MassHealth agency or its designee will specify on the prior authorization for CSN services the number of CSN hours that have been determined to be medically necessary and that are authorized for the member per calendar week and the duration of the prior authorization. Any CSN hours provided to the member by the independent nurse that exceed what the MassHealth agency or its designee has authorized in a calendar week are not payable by MassHealth except as described in 130 CMR 414.413(H). (E) If the frequency of the nursing services needs to be adjusted because (1) the member’s medical needs have changed from current authorization, the independent nurse must contact the MassHealth agency or its designee to request an adjustment to the prior authorization; or (2) there is a change in other nursing services or care from current authorization (e.g., PCA services, changes in adult day health or day habilitation schedules, adult foster care services), the independent nurse or the member must contact the MassHealth agency or its designee to request a review of the prior authorization. (F) Prior authorization for CSN services may be approved for more than one independent nurse or CSN agency, or both, provided that (1) each provider is authorized only for a specified portion of the member’s total hours; and (2) the sum total of the combined hours approved for co-vending providers does not exceed what the MassHealth agency or its designee has determined to be medically necessary and authorized for the member per calendar week, except as described in 130 CMR 414.413(H). (G) The independent nurse must contact the MassHealth agency or its designee for all prior authorization requests in accordance with the MassHealth agency’s administrative and billing regulations and instructions and must submit such requests to the appropriate addresses listed in Appendix A of the Independent Nurse Manual. (H) If there are unused hours of nursing services in a calendar week, they may be used at any time during the current authorized period. (I) In connection with a prior authorization, at the request of the MassHealth agency or its designee, the independent nurse is required to provide to the MassHealth agency or its designee a signed plan of care under 130 CMR 414.412 and supporting clinical documentation including, but not limited to, nursing progress notes, medication records, and clinical logs for all members authorized for CSN services. (J) The MassHealth agency or its designee may authorize additional medically necessary CSN services on a temporary, three-month basis if the member meets the clinical criteria for CSN services and the primary natural caregiver is unavailable because they (1) have an acute illness, have been hospitalized, or have a suspected illness; (2) have abandoned the member or have died in the past 30 days; (3) have a high-risk pregnancy that requires significant restrictions; (4) have given birth within the four weeks before a request for additional services; or (5) require surgery and/or are recovering from surgery in the hospital, in a rehabilitation facility, or at home. This temporary increase in authorized units will be evaluated at the end of the three-month period to determine whether additional authorization is needed. (K) MassHealth members and/or primary natural caregivers will determine when authorized independent nurses will be used in order to best support the member’s needs. This can include scheduling authorized nursing hours in increments of less than two hours in order to meet the member’s needs and best utilize authorized hours.