Procedure for Requesting Prior Authorization

(A) The provider must obtain prior authorization from the MassHealth agency before providing any service that requires prior authorization. The provider must submit the Request for Prior Authorization within 90 days of the date of service requested on the prescription. (B) The Request for Prior Authorization must document the adjusted acquisition cost (see 130 CMR 428.422) and the medical necessity of the requested service. The Request for Prior Authorization must contain the following documentation: (1) a copy of the invoice or invoices from the manufacturer for the equipment, disclosing all discounts; (2) a copy of a current prescription that must not be older than 90 days from the requested date of service (see 130 CMR 428.409 for information that must be included in the prescription); (3) if requested by the MassHealth agency, a current prosthetic evaluation for the equipment, performed independently of the provider by a licensed physician or prosthetist; (4) the date or projected date of service; (5) the projected duration of need for the equipment; and (6) if replacing existing equipment, the date the existing equipment was purchased.