Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 438.000 - Continuous Skilled Nursing Agency
Section 438.412 - Notice of Prior Authorization and Clinical Eligibility Determination
Universal Citation: 130 MA Code of Regs 130.438
Current through Register 1531, September 27, 2024
(A) Notice of Approval. For all approved prior authorization requests for CSN agency services, the MassHealth agency or its designee sends written notice to the member and the CSN agency, if applicable, specifying the frequency and duration of care authorized, and the effective date of the authorization.
(B) Notice of Modification and Right of Appeal.
(1) For all modified prior authorization
requests, the MassHealth agency or its designee notifies the member of the
modification, reason, member's right to appeal, and appeal procedure. The CSN
agency receives 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 modifies a prior
authorization request. The member must request a fair hearing in writing within
30 days after the date of the modification. The Office of Medicaid Board of
Hearings conducts 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 agency services, the MassHealth
agency or its designee notifies the member and the CSN agency provider of the
discontinuation and the reason for discontinuation. The member also receives
notification of the member's 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 agency services. The member must
request a fair hearing in writing within 30 days after the date of the
discontinuation. The Office of Medicaid Board of Hearings conducts 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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