Prior Authorization

The orthotics provider must obtain prior-authorization (PA) from the MassHealth agency or its designee for all orthotics or orthotic services identified as subject to PA in the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool or other guidance specified by MassHealth or its designee, or as otherwise required by 130 CMR 442.000 and 130 CMR 450.303: Prior Authorization. Prior authorization is a determination of medical necessity only, and does not establish or waive any other prerequisites for payment, such as member eligibility or requirements to seek payment from other liable parties. (A) Documentation of Medical Necessity. (1) PA requests must include: (a) a completed MassHealth Prior Authorization Request form (the MassHealth PA-1 form adopted by MassHealth or its designee); (b) a detailed written order that meets the requirements of 130 CMR 442.409(B); (c) for all orthotics that are identified as requiring individual consideration (IC) in the pricing regulation, 101 CMR 334.00: Protheses, Prosthetic Devices and Orthotic Devices and which are also identified as subject to prior authorization in the Orthotics and Prosthetics Payment and Guidelines Tool, Subchapter 6, or in other guidance issued by MassHealth or its designee: 1. a copy of the original invoice, if applicable, that reflects all discounts to be applied to determine the provider’s adjusted acquisition cost as defined in 101 CMR 334.02: Prostheses, Prosthetic Devices and Orthotic Devices; or 2. if the item has not been purchased by the provider at the time of the prior authorization request, or when the item being purchased is not an item that the provider normally purchases within its scope of business, MassHealth will accept a quote from the provider’s supplier. The quote must be on the supplier’s letterhead or form and must be addressed to the provider; and 3. any additional assessments of the member or other necessary information requested by the MassHealth agency or its designee, in support of the request for prior authorization. (B) 90-day Requirement for Submission of Prior Authorization Requests. The provider must submit the request for PA to MassHealth or its designee no later than 90 calendar days from the date the prescribing provider signed the detailed written order. Failure to submit the PA request within the 90- day period will result in a denial of the prior authorization request. (C) Prior Authorization Requests for Units in Excess of the Maximum Allowable Units. MassHealth requires PA for orthotics provided to the member if the number of units requested exceeds the maximum units described in the Orthotics and Prosthetics Payment and Coverage Guidelines Tool. (1) The provider must include documentation that supports the medical necessity of the additional units; (2) If the PA request is authorized by MassHealth or its designee, the provider must submit a separate claim with a different date of service than the date of service for the initial maximum number of units only for the number of excess units actually provided to the member, but in no case for a number of units that exceeds the excess units for which a PA has been authorized. (D) Prior Authorization Required before Delivery of Product. Orthotics providers must obtain prior authorization from MassHealth or its designee before delivery of a product to a MassHealth member. (E) Prior Authorization Requests for Members Who Have Other Insurance. For members for whom MassHealth is not the primary insurer and for whom the provider is seeking payment from another insurer, the provider must make diligent efforts to first identify and obtain payment from all other liable parties, including Medicare, before seeking payment from MassHealth in accordance with 130 CMR 450.316: Third-party Liability: Requirements. (F) Repairs of Orthotics. Providers must consult the Orthotics and Prosthetics Payment and Coverage Guidelines Tool, or other guidance as issued by MassHealth or its designee, to determine when PA is required for the repair of orthotics. (1) PA is required for repairs as indicated in the Orthotics and Prosthetics Payment and Coverage Guidelines Tool, including, but not limited to, repairs exceeding $1,000: (2) The orthotics provider must submit the following documentation with the PA request: (a) a completed MassHealth Prior Authorization Request (the MassHealth PA-1 form, adopted by MassHealth); (b) a detailed written order (only required if the provider requesting the repair is not the provider who initially supplied the item); (c) an invoice or quote for the repaired or replaced item; (d) a work order log with the estimated number of hours the repair will take; (e) a detailed description of the circumstances that made the repair necessary; and (f) an explanation as to why the repaired or replaced item is not covered under any warranty. (G) Assessment. The MassHealth agency may, at its discretion, require the provider of orthotics to submit an assessment of the member's condition and the objectives of the requested service in support of a PA request. The MassHealth agency may also, at its discretion, require an evaluation by the requesting provider’s ABC- or BOC-certified orthotist or pedorthist to determine whether the requested orthotic is useful to the member, given the member's physical condition and physical environment. (H) Recordkeeping. The provider must keep the PA request on file for the period of time required by 130 CMR 450.205: Recordkeeping and Disclosure. (I) Notice of Approval, Denial, or Modification of a Standard or Expedited Prior-authorization Request. (1) The MassHealth agency or its designee acts on prior authorization requests in accordance with 130 CMR 450.303: Prior Authorization. (2) Notice of Approval. If the MassHealth agency, or its designee, approves a prior authorization request for orthotics, the MassHealth agency or its designee will send notice of its decision to the member and the orthotics provider, within the timeframe specified at 130 CMR 450.303: Prior Authorization. (3) Notice of Denial or Modification. If the MassHealth agency, or its designee, denies or approves with a modification, a prior authorization request for orthotics, the MassHealth agency, or its designee, will notify the member and the orthotics provider, within the timeframe specified at 130 CMR 450.303: Prior Authorization. The notice will state the reason for the denial or modification, and will inform the member of the right to appeal and of the appeal procedure in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules. (4) Right of Appeal. A member may appeal a service denial or modification by requesting a fair hearing in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules. (5) 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 orthotics provider of the deferral, and 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 442.412 (I).