Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 414.000 - Independent Nurse
Section 414.414 - Notice of Approval or Denial of Prior Authorization
Universal Citation: 130 MA Code of Regs 130.414
Current through Register 1531, September 27, 2024
(A) Notice of Approval. For all approved prior authorization requests for nursing services, the MassHealth agency or its designee will send written notice to the member and the independent nurse specifying the frequency and duration of care authorized and the effective date of the authorization.
(B) Notice of Denial or Modification and Right of Appeal.
(1) For all denied or modified prior
authorization requests, the MassHealth agency or its designee will notify both
the member and the independent nurse of the denial or modification, reason,
right to appeal, and appeal procedure. The independent nurse will receive the
information about the modification and the reason from the MassHealth agency or
its designee.
(2) A member may
request a fair hearing from the MassHealth agency if the MassHealth agency or
its designee denies or modifies a prior authorization request. The member must
request a fair hearing in writing within 60 days after the date of the denial
or modification unless otherwise decided by EOHHS. The Office of Medicaid Board
of Hearings will conduct the hearing in accordance with 130 CMR 610.000:
MassHealth: Fair Hearing Rules.
(C) Notice of Discontinuation and Right of Appeal.
(1) For members
who no longer meet clinical criteria for CSN services, the MassHealth agency or
its designee will notify the member and the independent nurse of the
discontinuation and the reason for it. The member will also receive
notification of their right to appeal and the appeal procedure.
(2) A member may request a fair hearing from
the MassHealth agency if the MassHealth agency or its designee discontinues
authorization of CSN services. Any fair hearing request must be made in writing
within 30 days after the date of the discontinuation. The Office of Medicaid
Board of Hearings will conduct the hearing in accordance with 130 CMR 610.000:
MassHealth: Fair Hearing Rules.
Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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