Prior Authorization, Orders, Referrals, and Prescriptions

(A) Introduction. (1) Subchapter 6 of the Physician Manual lists codes that require prior authorization as a prerequisite for payment. The MassHealth agency does not pay for services if billed under any of these codes, unless the provider has obtained prior authorization from the MassHealth agency before providing the service. (2) A 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 health insurance payment. (B) Requesting Prior Authorization. All prior-authorization requests must be submitted in accordance with the instructions in Subchapter 5 of the Physician Manual. (C) Physician Services Requiring Prior Authorization. Services requiring prior authorization include, but are not limited to, the following: (1) certain surgery services, including reconstructive surgery and gender-affirming surgery; (2) nonemergency services provided to a member by an out-of-state physician who practices outside a 50-mile radius of the Massachusetts border; (3) certain vision care services; and (4) certain behavioral health services. 4. Program Regulations (D) Mental Health and Substance Abuse Services Requiring Prior Authorization. Members enrolled with the MassHealth behavioral health contractor require service authorization before certain mental health and substance abuse services are provided. For more information, see 130 CMR 450.124: Behavioral Health Services. (E) Therapy Services Requiring Prior Authorization. Prior authorization is required for the following therapy services provided by any MassHealth provider to eligible MassHealth members. (1) more than 20 occupational therapy visits or 20 physical-therapy visits, including group therapy visits, for a member within a 12 month period; and (2) more than 35 speech/language therapy visits, including group therapy visits, for a member within a 12-month period. (F) Other Services Requiring Prior Authorization, Orders, Referrals, or Prescriptions. Many other services require prior authorization, or must first be ordered, referred, prescribed, or otherwise have their need substantiated by a physician or other practitioner before the MassHealth agency will cover the service. When such a service is medically necessary for an eligible MassHealth member, a treating physician or other practitioner shall provide such orders, referrals, prescriptions, medical necessity documentation, certifications, plans of care, examinations, or take such other actions that the MassHealth agency requires as a condition of payment for the service. Coverage requirements for particular MassHealth services are contained in the applicable MassHealth program regulations and guidance and are found in the MassHealth Provider Library. These services include, but are not limited to, the following: (1) transportation; (2) drugs; (3) home health services; (4) nursing facility services; (5) durable medical equipment; and (6) therapy services.