Prior Authorization Requirements

(A) Prior authorization must be obtained from the MassHealth agency or its designee as a prerequisite for payment for CSN agency services and before services are provided to the member. Without such prior authorization, CSN agency services will not be paid by the MassHealth agency. (B) 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. (C) The MassHealth agency or its designee will conduct the assessment of need for CSN agency services, including CSN services and complex care assistant services, and coordinate other MassHealth LTSS for the member, as appropriate. When the MassHealth agency or its designee conducts an assessment of need for CSN agency services and authorizes CSN agency services for the member, the member will select the CSN agency or agencies that will be responsible for providing CSN agency services. The MassHealth agency or its designee will provide written notification of its assessment to the member and, if applicable, the CSN agency or agencies selected by the member. (D) At the request of the MassHealth agency or its designee, CSN agencies are required to provide a signed plan of care under 130 CMR 438.416 and supporting clinical documentation including, but not limited to, nursing progress notes, complex care assistant progress notes, medication records, and clinical logs to the MassHealth agency or its designee for all members authorized for CSN agency services. (E) The MassHealth agency or its designee will specify on the prior authorization for CSN agency services the number of CSN hours and complex care assistant hours, as applicable, that have been determined to be medically necessary and that are authorized for the provider to provide to the member per calendar week and the duration of the prior authorization. Any CSN hours or complex care assistant hours provided to the member by the CSN agency that exceed what the MassHealth agency or its designee has authorized in a calendar week are not payable by MassHealth, except as described at 130 CMR 438.411(F).   (F) If there are unused hours of CSN services in a calendar week, they may be used at any time during the current authorized period. (G) MassHealth members and/or primary natural caregivers will determine when authorized CSN hours and complex care assistant hours will be used in order to best support the member’s needs. This can include scheduling authorized service hours in increments of less than two hours in order to meet the member’s needs and best utilize authorized hours. (H) If the frequency of the member’s CSN agency services needs to be adjusted because (1) the member’s medical needs have changed from current authorization, the CSN agency must contact the MassHealth agency or its designee to request an adjustment to the prior authorization; (2) there is a change in other nursing and health care services or care from current authorization (for example, PCA services, changes in adult day health or day habilitation schedules, adult foster care services), the CSN agency or the member may contact the MassHealth agency or its designee to request a review of the prior authorization. (I) The MassHealth agency or its designee may authorize additional medically necessary CSN agency services on a temporary three-month basis if the member meets the clinical criteria for nursing services and the primary natural caregiver is temporarily unavailable because they (1) have an acute illness, have been hospitalized, or have a suspected illness; (2) have abandoned the member or have died within the past 30 days; (3) have a high-risk pregnancy that requires significant restrictions; (4) have given birth within the four weeks prior to a request for additional services; or (5) require surgery and/or are recovering from surgery in the hospital, in a rehabilitation facility, or at home. This temporary increase in authorized units will be evaluated at the end of the three-month period in order to determine whether additional authorization is needed. (J) Prior authorization for CSN services may be approved for more than one CSN agency or independent nurse, or both, provided that (1) each provider is authorized only for a specified portion of the member’s total hours; and (2) the sum total of the combined hours approved for co-vending providers does not exceed what the MassHealth agency or its designee has determined to be medically necessary and authorized for the member per calendar week.