Current through Register 1531, September 27, 2024
The orthotics provider must obtain prior-authorization (PA)
from MassHealth or its designee for all orthotics or orthotic services
identified as subject to PA in the MassHealth Orthotics and Prosthetics Payment
and Coverage Guidelines Tool or other guidance specified by MassHealth or its
designee, or as otherwise required by 130 CMR 442.000 and
130
CMR 450.303: Prior
Authorization. Prior authorization is a determination of medical
necessity only, and does not establish or waive any other prerequisites for
payment, such as member eligibility or requirements to seek payment from other
liable parties.
(A)
Documentation of Medical Necessity.
(1) PA requests must include:
(a) a completed MassHealth Prior
Authorization Request form (the MassHealth PA-1 form adopted by MassHealth or
its designee);
(b) a detailed
written order that meets the requirements of
130
CMR 442.409(B);
(c) for all orthotics that are identified as
requiring individual consideration (IC) in the pricing regulation, 101 CMR
334.00:
Protheses, Prosthetic Devices and Orthotic Devices and
which are also identified as subject to prior authorization in the Orthotics
and Prosthetics Payment and Guidelines Tool, Subchapter 6, or in other guidance
issued by MassHealth or its designee:
1. a
copy of the original invoice, if applicable, that reflects all discounts to be
applied to determine the provider's adjusted acquisition cost as defined in
101
CMR 334.02: Prostheses, Prosthetic
Devices and Orthotic Devices; or
2. if the item has not been purchased by the
provider at the time of the prior authorization request, or when the item being
purchased is not an item that the provider normally purchases within its scope
of business, MassHealth will accept a quote from the provider's supplier. The
quote must be on the supplier's letterhead or form and must be addressed to the
provider; and
3. any additional
assessments of the member or other necessary information requested by the
MassHealth agency or its designee, in support of the request for prior
authorization.
(B)
90-day Requirement for
Submission of Prior Authorization Requests. The provider must
submit the request for PA to MassHealth or its designee no later than 90
calendar days from the date the prescribing provider signed the detailed
written order. Failure to submit the PA request within the 90-day period will
result in a denial of the prior authorization request.
(C)
Prior Authorization Requests
for Units in Excess of the Maximum Allowable Units. MassHealth
requires PA for orthotics provided to the member if the number of units
requested exceeds the maximum units described in the Orthotics and Prosthetics
Payment and Coverage Guidelines Tool.
(1) The
provider must include documentation that supports the medical necessity of the
additional units;
(2) If the PA
request is authorized by MassHealth or its designee, the provider must submit a
separate claim with a different date of service than the date of service for
the initial maximum number of units only for the number of excess units
actually provided to the member, but in no case for a number of units that
exceeds the excess units for which a PA has been
authorized.
(D)
Prior Authorization Required before Delivery of
Product. Orthotics providers must obtain prior authorization from
MassHealth or its designee before delivery of a product to a MassHealth
member.
(E)
Prior
Authorization Requests for Members Who Have Other Insurance. For
members for whom MassHealth is not the primary insurer and for whom the
provider is seeking payment from another insurer, the provider must make
diligent efforts to first identify and obtain payment from all other liable
parties, including Medicare, before seeking payment from MassHealth in
accordance with
130
CMR 450.316: Third-party Liability:
Requirements.
(F)
Repairs of Orthotics. Providers must consult the
Orthotics and Prosthetics Payment and Coverage Guidelines Tool, or other
guidance as issued by MassHealth or its designee, to determine when PA is
required for the repair of orthotics.
(1) PA
is required for repairs as indicated in the Orthotics and Prosthetics Payment
and Coverage Guidelines Tool including, but not limited to, repairs exceeding
$1,000:
(2) The orthotics provider
must submit the following documentation with the PA request:
(a) a completed MassHealth Prior
Authorization Request (the MassHealth PA-1 form adopted by
MassHealth);
(b) a detailed written
order (only required if the provider requesting the repair is not the provider
who initially supplied the item);
(c) an invoice or quote for the repaired or
replaced item;
(d) a work order log
with the estimated number of hours the repair will take;
(e) a detailed description of the
circumstances that made the repair necessary; and
(f) an explanation as to why the repaired or
replaced item is not covered under any warranty.
(G)
Assessment. The
MassHealth agency may, at its discretion, require the provider of orthotics to
submit an assessment of the member's condition and the objectives of the
requested service in support of a PA request. The MassHealth agency may also,
at its discretion, require an evaluation by the requesting provider's ABC- or
BOC-certified orthotist or pedorthist to determine whether the requested
orthotic is useful to the member, given the member's physical condition and
physical environment.
(H)
Recordkeeping. The provider must keep the PA request
on file for the period of time required by
130
CMR 450.205: Recordkeeping and
Disclosure.
(I)
Notice of Approval, Denial, or Modification of a
Prior-Authorization Request.
(1)
Notice of Approval. If the MassHealth agency, or its
designee, approves a prior authorization request for orthotics, the MassHealth
agency or its designee will send notice of its decision to the member and the
orthotics provider.
(2)
Notice of Denial or Modification. If the MassHealth
agency, or its designee, denies or approves with a modification, a prior
authorization request for orthotics, the MassHealth agency, or its designee,
will notify the member and the orthotics provider. The notice will state the
reason for the denial or modification, and will inform the member of the right
to appeal and of the appeal procedure in accordance with 130 CMR 610.000:
MassHealth: Fair Hearing Rules.
(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.
(4)
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 orthotics provider of the deferral, and 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 442.412(I).
