Notice of Prior Authorization and Clinical Eligibility Determination

(A) Notice of Approval. For all approved prior authorization requests for CSN agency services, the MassHealth agency or its designee sends written notice to the member and the CSN agency, if applicable, specifying the frequency and duration of care authorized, and the effective date of the authorization. (B) Notice of Modification and Right of Appeal. (1) For all modified prior authorization requests, the MassHealth agency or its designee notifies the member of the modification, reason, member’s right to appeal, and appeal procedure. The CSN agency receives the information about the modification and the reason from the MassHealth agency or its designee. (2) A member may request a fair hearing from the MassHealth agency if the MassHealth agency or its designee modifies a prior authorization request. The member must request a fair hearing in writing within 30 days after the date of the modification. The Office of Medicaid Board of Hearings conducts the hearing in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules. (C) Notice of Discontinuation and Right of Appeal. (1) For members who no longer meet clinical criteria for CSN agency services, the MassHealth agency or its designee notifies the member and the CSN agency provider of the discontinuation and the reason for discontinuation. The member also receives notification of the member’s right to appeal, and the appeal procedure. (2) A member may request a fair hearing from the MassHealth agency if the MassHealth agency or its designee discontinues authorization of CSN agency services. The member must request a fair hearing in writing within 30 days after the date of the discontinuation. The Office of Medicaid Board of Hearings conducts the hearing in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules.