Prior Authorization

In certain instances, the MassHealth agency requires providers to obtain prior authorization to provide medical services. These instances are identified in the billing instructions, program regulations, associated lists of service codes and service descriptions, provider bulletins, and other written issuances from the MassHealth agency. Such information is available on the MassHealth website at https://www.mass.gov/masshealth-provider-library, and copies may be obtained upon request. The provider must submit all prior authorization requests in accordance with the MassHealth agency’s instructions. 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. (A) For standard prior authorization decisions, the MassHealth agency acts on appropriately completed and submitted prior authorization requests within the following time periods. (1) For pharmacy services—by telephone or other telecommunication device within 24 hours of the prior authorization request. The MassHealth agency will authorize at least a 72-hour supply of a prescription drug to the extent required by federal law. (See 42 U.S.C. 1396r- 8(d)(5).) (2) For transportation to medical services—within seven calendar days after a prior authorization request, or the number of days, if less than seven, necessary to avoid any serious and imminent risk to the health or safety of the member that might arise if the MassHealth agency did not act before the full seven days had elapsed. (a) For nonemergency transportation between an acute care hospital and post–acute care facility—within the next business day. 3. Billing Regulations (130 CMR 450.000) (3) For all other MassHealth services—within seven calendar days after a prior authorization request. (B) For expedited prior authorization decisions for all MassHealth services, the MassHealth agency shall issue a prior authorization decision within 72 hours after receiving an appropriately submitted and completed prior authorization request. Providers must request an expedited prior authorization decision in a manner and format specified by the MassHealth agency. (C) The following rules apply for prior authorization requests. (1) The date of any prior authorization request is the date the request is received by the MassHealth agency, if the request conforms to all applicable submission requirements, including but not limited to the form, the place to which the request is sent, and required documentation. (2) For standard prior authorization decisions, if a provider submits a prior authorization request that is incomplete or does not comply with all submission requirements, the MassHealth agency informs the provider (a) of the relevant requirements, including any applicable program regulations; (b) that the MassHealth agency will act on the request within the time limits specified in 130 CMR 450.303 if it receives the required information within 14 calendar days after the date on the MassHealth-issued notice that identifies that the request is incomplete and/or does not comply with all submission requirements; and (c) that if the required information is not submitted to the MassHealth agency by 14 calendar days after the date on the MassHealth-issued notice that identifies that the request is incomplete and/or does not comply with all submission requirements, the MassHealth agency will issue a prior authorization decision based on the information that has been submitted to the MassHealth agency and the applicable MassHealth rules and regulations. (3) Unless the MassHealth prior authorization decision states otherwise, a service is authorized on the date the MassHealth agency sends a notice of its prior authorization decision to the member or someone acting on the member’s behalf. (D) The MassHealth agency does not act on prior authorization requests for (1) covered services that do not require prior authorization; or (2) noncovered services, except to the extent that MassHealth regulations specifically allow for such prior authorization requests.