Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 410.000 - Outpatient hospital services
Section 410.408 - Prior Authorization
Current through Register 1531, September 27, 2024
(A) For certain outpatient services described in 130 CMR 410.000, the MassHealth agency requires that the hospital outpatient department obtain prior authorization. No payment is made for outpatient services whenever a hospital is required, but fails, to obtain prior authorization from the MassHealth agency or its designee. It is the responsibility of the hospital to obtain the necessary prior authorization.
(B) 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.
(C) All requests for prior authorization must be submitted in accordance with the instructions in Subchapter 5 of the Outpatient Hospital Manual. For more information on requests for prior authorization, see 130 CMR 450.303: Prior Authorization.
(D) Members enrolled with a MassHealth managed care provider require service authorization before certain behavioral health services are provided. For more information, see 130 CMR 450.124: Behavioral Services.
(E) The hospital must obtain prior authorization for the following outpatient therapy services:
