PCA Program: Prior Authorization for PCA Services

The PCM agency must request prior authorization from the MassHealth agency as a prerequisite to payment for PCA services. 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 utilization of other potential sources of health care as described in 130 CMR 503.007: Potential Sources of Health Care and 517.008: Potential Sources of Health Care. Prior authorization for PCA services does not authorize member scheduling of PCA overtime, which is described in 130 CMR 422.418. All requests for prior authorization for PCA services must include the provider number of the fiscal intermediary and be submitted on MassHealth forms in accordance with the billing instructions in Subchapter 5 of the Personal Care Manual and 130 CMR 422.416. The MassHealth agency responds to requests for prior authorization in accordance with 130 CMR 450.303: Prior Authorization. (A) Initial Request for Prior Authorization for PCA Services. With the exception of 130 CMR 422.416(D), PCM agencies must submit the initial request for prior authorization for PCA services to the MassHealth agency within 45 days of the date of the receipt of the PCP Summary Form. Requests for prior authorization for PCA services must include (1) the completed MassHealth Application for PCA Services, PCP Summary Form, and MassHealth Evaluation for PCA Services; (2) the completed MassHealth Prior Authorization Request form; (3) any documentation that supports the member’s need for PCA services. This documentation must (a) identify a permanent or chronic disability that impairs the member’s ability to perform ADLs and IADLs without physical assistance; and (b) state that the member requires physical assistance with two or more ADLs as defined in 130 CMR 422.410(A); and (4) the completed and signed assessment of the member’s ability to manage the PCA program independently. (B) Adjustment of Current Prior Authorization. Prior authorization requests to increase or decrease the number of hours of PCA services must be submitted to the MassHealth agency by the member’s PCM agency in writing within 30 days of the member or surrogate request, and include (1) a copy of the original prior authorization request and PCA evaluation; (2) a written summary of the specific adjustment requested that includes the reason for the adjustment and the specific ADLs or IADLs for which an increase or decrease in PCA services is being requested, including the number of units, the number of hours, and the duration of time for which the adjustment is being requested; and (3) other supporting documentation, such as a letter from the member’s physician, nurse practitioner, or physician assistant stating that the need for an adjustment in the member’s authorized number of hours of PCA services is a result of changes in the member’s medical condition, functional status, or living situation that affects the member’s ability to perform ADLs and IADLs without physical assistance. (C) Continuation of PCA Services. To ensure the continuation of PCA services, PCM agencies must request prior authorization from the MassHealth agency at least 21 days before the expiration date of the current prior authorization period. The PCM agency must include in its prior authorization request the documentation described in 130 CMR 422.416(A) but an electronic medical record (EMR) may be submitted in lieu of a PCP Summary Form if the consumer does not require complex care tasks. The MassHealth agency will continue to pay for PCA services during its review of the new PA request only if the MassHealth agency has received the new prior authorization request at least 21 days before the expiration of the current prior authorization period. If the MassHealth agency does not receive the new prior authorization request at least 21 days before the expiration date, the MassHealth agency may stop payment for PCA services after the expiration date. (D) Special Conditions. (1) The MassHealth agency, or its designee, reserves the right to conduct the PCA evaluation for purposes of authorizing PCA services or coordinating other MassHealth services, as appropriate. When the MassHealth agency, or its designee, conducts a PCA evaluation and authorizes PCA services for the member, the member will select the PCM agency that will be responsible for providing PCM functions. The MassHealth agency, or its designee, will provide written notification to the PCM agency selected by the member, who must provide all other PCM functions, as appropriate, including, but not limited to, providing orientation, functional skills training, and developing, in conjunction with the member, a service agreement. (2) When the MassHealth agency or its designee conducts an evaluation of the member’s need for PCA services, the MassHealth agency will not pay a PCM agency for an evaluation. (3) The PCM agency must contact MassHealth, or its designee, within 24 hours of an inquiry for PCA services for a member who is being discharged from a nursing facility or other inpatient facility. The MassHealth agency may, at its discretion, exercise its right to conduct the PCA evaluation and coordinate other MassHealth services in accordance with 130 CMR 422.416(D). (E) Utilization of Authorized PCA Services. (1) Notification. If the MassHealth agency approves or modifies a prior authorization request for PCA services, the notice to the member will specify the number of hours of PCA services that the MassHealth agency determines are medically necessary and reimbursable by MassHealth at the PCA rate for each week during the duration of the member’s prior authorization period. (2) Adjustments to PCA Hours. PCM agencies may request an adjustment to the member’s authorized number of hours of PCA services if there is a change in the member’s medical or functional status that affects the member’s ability to perform ADLs or IADLs without physical assistance. See 130 CMR 422.416(B). (3) Overutilization of PCA Hours. (a) The fiscal intermediary will notify the member and the PCM agency when the member repeatedly submits activity forms in excess of the PCA hours per week that the MassHealth agency has authorized pursuant to 130 CMR 422.416(E). (b) When contacted by the fiscal intermediary pursuant to 130 CMR 422.416(E)(3)(a), the PCM agency will provide functional skills training to the member or surrogate or administrative proxy, if appropriate, to, at minimum 1. inform the member and surrogate or administrative proxy of the member’s and surrogate’s or administrative proxy’s responsibility to utilize PCA services in accordance with the number PCA hours per week authorized by the MassHealth agency pursuant to 130 CMR 422.416(E) and provide instruction regarding proper submission of activity forms, as appropriate; and 2. inform the member that the member may, if appropriate, request an adjustment in accordance with 130 CMR 422.416(B). (c) If the member continues to overutilize PCA services after intervention from the fiscal intermediary and the PCM agency in accordance with 130 CMR 422.416(E)(3)(a) and (b), the fiscal intermediary will notify the MassHealth agency. (d) The MassHealth agency reserves the right to take action to ensure that the PCA services reimbursed by the MassHealth agency are medically necessary, including, but not limited to, directing the fiscal intermediary to stop payment of PCA hours submitted on the activity form that are in excess of the number of PCA hours per week authorized by the MassHealth agency pursuant to 130 CMR 422.416(E). (e) The MassHealth agency, the fiscal intermediary, and the PCM agency are not responsible for reimbursement of PCA services provided to a member in excess of the total number of hours authorized by the MassHealth agency during a prior authorization period.