Current through Register 1531, September 27, 2024
(A)
Clinical
Assessment. As part of the prior authorization process, members
seeking AFC must undergo a clinical assessment to assess the member's clinical
status and need for AFC. Completed clinical assessment documentation must be
submitted to MassHealth, or its designee, in the form and format requested by
the MassHealth agency. A new clinical assessment is required annually and upon
significant change.
(B)
Prior Authorization.
(1) As a prerequisite for payment of AFC, the
AFC provider must obtain prior authorization from the MassHealth agency or its
designee before the first date of service delivery and annually thereafter, and
upon significant change.
(2) Prior
authorization determines the medical necessity for AFC as described under
130
CMR 408.416 and in accordance with
130
CMR 450.204: Medical
Necessity.
(3) Prior
authorization may specify the service level for payment for the
service.
(4) Prior authorization
does not establish or waive any other prerequisites for payment such as the
member's financial eligibility described in
130 CMR
503.007: Potential Sources of Health
Care and
130 CMR
517.008
: Potential Sources of Health
Care.
(5) When submitting
a request for prior authorization for payment of AFC to the MassHealth agency,
or its designee, the AFC provider must submit requests in the form and format
as required by the MassHealth agency. The AFC provider must include all
required information including, but not limited to, documentation of the
completed clinical assessment conducted by the MassHealth agency or its
designee; other nursing, medical or psychosocial evaluations or assessments;
and any other documentation that the MassHealth agency, or its designee,
requests in order to complete the review and determination of prior
authorization.
(6) In making its
prior authorization determination, the MassHealth agency or its designee, may
require additional assessments of the member or require other necessary
information in support of the request for prior authorization.
(C)
Notice of
Determination of Prior Authorization.
(1)
Notice of
Approval. If the MassHealth agency or its designee approves a
request for prior authorization, it will send written notice to the member and
the AFC provider.
(2)
Notice of Denial or Service Modification. If the
MassHealth agency or its designee denies, or approves with a service
modification, request for prior authorization of AFC, the MassHealth agency or
its designee will notify both the member and the AFC provider. The notice will
state the reason for the denial or service modification and contain information
about the member's right to appeal and the appeal procedure.
(3)
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.
(D)
Review Requirement. The MassHealth agency, or its
designee, may at any time review prior authorization of MassHealth members
including, but not limited to, instances in which there has been a significant
change in the member's status as defined in
130 CMR
408.402.
