Prior Authorization

(A) Services that Require Prior Authorization. The MassHealth agency requires that doulas obtain prior authorization as a prerequisite to payment for more than eight hours of perinatal visits per member per perinatal period. (B) Submission Requirement. The doula must submit all prior authorization requests in accordance with the billing instructions in Subchapter 5 of the Doula Manual. 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. See 130 CMR 450.303: Prior Authorization for additional information about prior authorization. (C) Notice of Approval or Denial of Prior Authorization. (1) Notice of Approval. For all approved prior authorization requests for doula services, the MassHealth agency sends written notice to the member and the doula about the frequency, duration, and intensity of care authorized, and the effective date of authorization. (2) Notice of Denial or Modification and Right of Appeal. (a) For all denied or modified prior authorization requests, the MassHealth agency notifies both the member and the doula of the denial or modification and the reason. In addition, the member will receive information about the member’s right to appeal and the appeal procedure. (b) A member may request a fair hearing from the MassHealth agency if it denies or modifies a prior authorization request. The member must request a fair hearing in writing within 30 days after the date of receipt of the notice of denial or modification. The MassHealth Board of Hearings will conduct the hearing in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules.