Prior Authorization

(A) General Terms. (1) Prior authorization (PA) must be obtained from the MassHealth agency or its designee as a prerequisite to payment for visits in excess of the number of visits described in 130 CMR 432.417(B). Without such prior authorization, the MassHealth agency will not pay therapy providers for services in excess of the number of visits described in 130 CMR 432.417(B). (2) 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 resort to third-party health insurance payment, including Medicare. The MassHealth agency or its designee acts on prior-authorization requests in accordance with 130 CMR 450.303. See 130 CMR 450.303: Prior Authorization for additional information. (3) Approvals for prior authorization specify the number of hours, visits, or units for each service that are medically necessary and payable each calendar week and the duration of the prior authorization period. The authorization is issued in the member’s name and specifies the frequency and duration of care for each service approved per calendar week. (4) The therapy provider must submit all prior-authorization requests in accordance with 130 CMR 450.303: Prior Authorization and any relevant MassHealth agency instructions. (5) In conducting prior authorization review, the MassHealth agency or its designee will apply any applicable MassHealth medical necessity guidelines and may refer the member for an independent clinical assessment to inform the determination of medical necessity for therapy services. (6) If the number of prior-authorized services needs to be adjusted because the member’s medical needs have changed, the therapy provider must request a prior authorization adjustment from the MassHealth agency or its designee. (B) Services that Require Prior Authorization. The MassHealth agency requires that the therapist obtain prior authorization as a prerequisite to payment for the following services to eligible MassHealth members: (1) more than 20 occupational-therapy visits or 20 physical-therapy visits, including group- therapy visits but not including evaluations, for a member in a 12-month period; (2) more than 35 speech/language therapy visits, including group-therapy visits but not including evaluations, for a member in a 12-month period; and (3) more than two evaluations in a 12-month period. (C) Submission Requirement. For all prior-authorization requests, the therapist must include the prescription for services that identifies the member’s diagnosis, frequency, and duration of therapy services, and a description of the intended therapy intervention, as well as all forms and documentation as designated by the MassHealth agency. The therapy provider should complete a prior-authorization request for therapy services through the LTSS Provider Portal in accordance with 130 CMR 432.417(B), as applicable. (D) Members in Capitated Programs. For those members who are enrolled in MassHealth capitated programs, the therapy provider must follow the capitated program’s specific prior authorization procedures, where applicable, for therapy services. (E) Notice of Approval, Deferral, or Denial of Prior Authorization. (1) Notice of Approval. For all approved prior-authorization requests for therapy services, the MassHealth agency or its designee sends written notice to the member and the therapist about the frequency, duration, and intensity of care authorized, and the effective date of authorization. (2) Notice of Denial or Modification and Right of Appeal. (a) For all denied or modified prior-authorization requests, the MassHealth agency or its designee notifies both the member and the therapy provider of the denial or modification and the reason. In addition, the member will receive information about the member’s right to appeal and the appeal procedure. (b) A member may request a fair hearing if the MassHealth agency or its designee denies or modifies a prior-authorization request. The member must request a fair hearing in writing within 30 days after the date of receipt of the notice of denial or modification. The Office of Medicaid Board of Hearings will conduct the hearing in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules. (3) 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 therapy provider of the deferral, the reason for the deferral, and provide an opportunity for the provider 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 432.417(E). See 130 CMR 450.303.