Prior Authorization

(A) The Division requires that the provider obtain prior authorization as a prerequisite to payment for the oxygen and respiratory therapy equipment and services listed in 130 CMR 427.410 and 427.411, except as specified in 130 CMR 427.427(B). Prior authorization determines only the medical necessity of the authorized item or service and does not waive any other prerequisites to payment such as recipient eligibility or resort to health insurance payment. (B) Providers must submit requests for prior authorization in accordance with the instructions in Subchapter 5 of the Oxygen and Respiratory Therapy Equipment Manual. Before determining the medical necessity of an item or service for which prior authorization is requested, the Division may, at its discretion, require the prescriber to submit an assessment of the recipient's pulmonary disability and to describe the specific therapeutic goals of the requested service. (C) For each item requested, the prior-authorization request must include an invoice that reflects the provider's adjusted acquisition cost as described in 130 CMR 427.420. The invoice must be placed in the recipient's record and made available to the Division pursuant to 130 CMR 427.430. (D) The provider must submit the prior-authorization request within 90 days of the requested date of service (date of delivery). Failure to submit the request within this 90-day period will result in denial of the request. (E) The Division will send written notification of the prior authorization decision to the recipient and the provider. The notification will indicate approval, deferral because additional information is necessary, modification, or denial. Notification of denial will include the reason for denial. The recipient, the provider, and the prescriber have the right to resubmit a request and furnish additional information. The recipient may appeal the denial of a prior-authorization request within 30 days after the date of the notice of denial. Procedures for such an appeal are set forth in 130 CMR 610.000.