Notice of Approval or Denial of Prior Authorization

(A) Notice of Approval. For all approved prior authorization requests for nursing services, the MassHealth agency or its designee will send written notice to the member and the independent nurse specifying the frequency and duration of care authorized and the effective date of the authorization. (B) Notice of Denial or Modification and Right of Appeal. (1) For all denied or modified prior authorization requests, the MassHealth agency or its designee will notify both the member and the independent nurse of the denial or modification, reason, right to appeal, and appeal procedure. The independent nurse will receive the information about the modification and the reason from the MassHealth agency or its designee. (2) A member may request a fair hearing from the MassHealth agency if the MassHealth agency or its designee denies or modifies a prior authorization request. The member must request a fair hearing in writing within 60 days after the date of the denial or modification unless otherwise decided by EOHHS. The Office of Medicaid Board of Hearings will conduct the hearing in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules. (C) Notice of Discontinuation and Right of Appeal. (1) For members who no longer meet clinical criteria for CSN services, the MassHealth agency or its designee will notify the member and the independent nurse of the discontinuation and the reason for it. The member will also receive notification of their right to appeal and the appeal procedure. (2) A member may request a fair hearing from the MassHealth agency if the MassHealth agency or its designee discontinues authorization of CSN services. Any fair hearing request must be made in writing within 30 days after the date of the discontinuation. The Office of Medicaid Board of Hearings will conduct the hearing in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules.