Prior Authorization

(A) Services that require prior authorization as a prerequisite for payment are identified in 130 CMR 428.000 or are listed in Subchapter 6 of the Prosthetics Manual with the designation (P.A.) appearing after the service description. To determine if prior authorization is required, the provider should review both 130 CMR 428.000 and Subchapter 6. Prior authorization determines only the medical necessity of the prescribed item or service and does not waive any other prerequisites to payment such as member eligibility or resort to health-insurance payment. (B) The provider must request prior authorization in accordance with the billing instructions in Subchapter 5 of the Prosthetics Manual. Before determining the medical necessity of an item or service for which prior authorization is requested, the MassHealth agency may, at its discretion, require the prescriber to submit an assessment of the member's condition and the objectives of the requested service. The MassHealth agency may also, at its discretion, require an evaluation by a licensed prosthetist to determine whether the requested prosthetic service is useful to the member, given the member's physical condition and physical environment. (C) Notice of Approval, Denial, or Modification of a Standard or Expedited Prior-authorization Request (1) The MassHealth agency or its designee acts on prior authorization requests in accordance with 130 CMR 450.303: Prior Authorization. (2) Notice of Approval. If the MassHealth agency or its designee approves a prior authorization request for DME, the MassHealth agency will send notice of its decision to the member and the DME provider, within the timeframe specified at 130 CMR 450.303: Prior Authorization. (3) Notice of Denial or Modification. If the MassHealth agency or its designee denies or approves with a modification a prior authorization request for DME, the MassHealth agency or its designee will notify the member and the DME provider, within the timeframe specified at 130 CMR 450.303: Prior Authorization. The notice will state the reason for the denial or modification and will inform the member of the right to appeal and of the appeal procedure in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules. (4) Right of Appeal. A member may appeal a service denial or modification by requesting a fair hearing in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules. (5) Notice of Deferral. If the MassHealth agency or its designee defers a prior authorization request due to an incomplete submission or lack of documentation to support medical necessity, the MassHealth agency or its designee will notify the member and the DME provider of the deferral and the reason for the deferral and will give the provider an opportunity to submit the incomplete or missing documentation. If the provider does not submit the required information within the timeframe specified at 130 CMR 450.303: Prior Authorization, the MassHealth agency or its designee will make a decision on the prior authorization request using all documentation and forms submitted to the MassHealth agency and will send notice of its decision to the provider and the member in accordance with 130 CMR 428.412(C).