Current through Register 1531, September 27, 2024
In certain instances, the MassHealth agency requires providers
to obtain prior authorization to provide medical services. These instances are
identified in the billing instructions, program regulations, associated lists
of service codes and service descriptions, provider bulletins, and other
written issuances from the MassHealth agency. Such information including, but
not limited to, the MassHealth Drug List is available on the MassHealth website
at www.mass.gov/druglist , and
copies may be obtained upon request. The provider must submit all
prior-authorization requests in accordance with the MassHealth agency
instructions. 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.
(A) The MassHealth agency
acts on appropriately completed and submitted requests for prior authorization
within the following time periods.
(1) For
pharmacy services - by telephone or other telecommunication device within 24
hours of the request for prior authorization. The MassHealth agency will
authorize at least a 72-hour supply of a prescription drug to the extent
required by federal law. (See
42 U.S.C.
1396r-8(d)(5).)
(2) For transportation to medical services -
within seven calendar days after a request for service, or the number of days,
if less than seven, necessary to avoid any serious and imminent risk to the
health or safety of the member that might arise if the MassHealth agency did
not act before the full seven days have elapsed.
(3) For independent nurse services - within
14 calendar days after a request for service.
(4) For durable medical equipment - within 15
calendar days after a request for service.
(5) For all other MassHealth services -
within 21 calendar days after a request for service.
(B) The following rules apply for
prior-authorization requests.
(1) The date of
any prior-authorization request is the date the request is received by the
MassHealth agency, if the request conforms to all applicable submission
requirements including, but not limited to, the form, the address to which the
request is sent, and required documentation.
(2) If a provider submits a request that does
not comply with all submission requirements, the MassHealth agency informs the
provider
(a) of the relevant requirements,
including any applicable program regulations;
(b) that the MassHealth agency will act on
the request within the time limits specified in 130 CMR 450.303 if the required
information is received by the MassHealth agency within four calendar days
after the request; and
(c) that if
the required information is not submitted within four calendar days, the
MassHealth agency's decision may be delayed by the time elapsing between the
four days and when the MassHealth agency receives the necessary
information.
(3) A
service is authorized on the date the MassHealth agency sends a notice of its
decision to the member or someone acting on the member's behalf.
(C) The MassHealth agency does not
act on requests for prior authorization for
(1) covered services that do not require
prior authorization; or
(2)
noncovered services, except to the extent that MassHealth regulations
specifically allow for prior-authorization requests.
