Current through Register 1531, September 27, 2024
(A)
General Terms.
(1)
Prior authorization (PA) must be obtained from the MassHealth agency or its
designee as a prerequisite to payment for visits in excess of the number of
visits described in 130 CMR 432.417(B). Without such prior authorization, the
MassHealth agency will not pay therapy providers for services in excess of the
number of visits described in 130 CMR 432.417(B).
(2) 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
third party health insurance payment, including Medicare. See
130 CMR
450.303: Prior Authorization
for additional information about prior authorization.
(3) Approvals for prior authorization specify
the number of hours, visits, or units for each service that are medically
necessary and payable each calendar week and the duration of the prior
authorization period. The authorization is issued in the member's name and
specifies frequency and duration of care for each service approved per calendar
week.
(4) The therapy provider must
submit all prior authorization requests in accordance with
130 CMR
450.303: Prior Authorization
and any relevant MassHealth agency instructions.
(5) In conducting prior authorization review,
the MassHealth agency or its designee will apply any applicable MassHealth
medical necessity guidelines and may refer the member for an independent
clinical assessment to inform the determination of medical necessity for
therapy services.
(6) If the number
of prior-authorized services need to be adjusted because the member's medical
needs have changed, the therapy provider must request a prior authorization
adjustment from the MassHealth agency or its designee.
(B)
Services that Require Prior
Authorization. The MassHealth agency requires that the therapist
obtain prior authorization as a prerequisite to payment for the following
services to eligible MassHealth members:
(1)
more than 20 occupational-therapy visits or 20 physical-therapy visits,
including group-therapy visits but not including evaluations, for a member in a
12-month period;
(2) more than 35
speech/language therapy visits, including group-therapy visits but not
including evaluations, for a member in a 12-month period;
(3) more than two evaluations in a 12-month
period.
(C)
Submission Requirement. For all prior-authorization
requests, the therapist must include the prescription for services that
identifies the member's diagnosis, frequency, and duration of therapy services,
and a description of the intended therapy intervention, as well as all forms
and documentation as designated by the MassHealth agency. The therapy provider
should complete a prior authorization request for prior authorization requests
for therapy services through the LTSS Provider Portal in accordance with 130
CMR 432.417(B), as applicable.
(D)
Members in Capitated Programs. For those members who
are enrolled in MassHealth capitated programs, the therapy provider must follow
the capitated program's specific prior authorization procedures, where
applicable, for therapy services.
(E)
Notice of Approval, Deferral,
or Denial of Prior Authorization.
(1)
Notice of
Approval. For all approved prior-authorization requests for
therapy services, the MassHealth agency or its designee sends written notice to
the member and the therapist 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 or its designee notifies
both the member and the therapy provider 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 if
the MassHealth agency or its designee 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 Office of
Medicaid Board of Hearings will conduct the hearing in accordance with 130 CMR
610.000: MassHealth: Fair Hearing Rules.
(3)
Notice of
Deferral. If the MassHealth agency or its designee defers a prior
authorization request due to an incomplete submission or lack of documentation
to support medical necessity, the MassHealth agency or its designee will notify
the member and therapy provider of the deferral, the reason for the deferral,
and provide an opportunity for the provider to submit the incomplete or missing
documentation.
If the provider does not submit the required information within
21 calendar days of the date of deferral, the MassHealth agency or its designee
will make a decision on the prior authorization request using all documentation
and forms submitted to the MassHealth agency and will send notice of its
decision to the provider and the member in accordance with 130 CMR
432.417(E).
