Prior Authorization Request 
MassHealth reviews requests for prior authorization on the basis of medical necessity only. If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, including current member eligibility, other insurance, and program restrictions. MassHealth will notify the provider and 
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member of its decision. Providers must complete items 1-21 or risk delays. 

PROVIDER INFORMATION SECTION MEMBER INFORMATION SECTION 

INSTRUCTIONS FOR COMPLETING THE PA-1 FORM (PLEASE PRINT OR TYPE.) 
General Instructions
  Complete Items 1 - 21 only. Enter all dates in mm/dd/yyyy format. Below are instructions for specific fields. All other fields are self-explanatory. 
(A) Provider Information Section  
Item 1  Provider’s Name, Address, and Tel. No.  Enter the provider’s name, address, and phone number (including area code).  
Item 2  Provider ID/Loc or NPI  Enter the nine-digit requesting provider ID followed by the one-character location code. If not available, enter the requesting provider’s 10-digit national provider identifier.  
Item 3  PA Assignment  Select the type of PA you are requesting from the following list. Basic Medical Medical Pharmacy DMR PCA Services PCA Services Pediatric PCA Services PERS Physician-Adult Physician-Pediatric Private Duty Nursing Skilled Nursing Vision Other Durable Medical Equipment Absorbent Products DME – Other Enterals Hearing Services Mobility and Repairs Orthotics and Prosthetics Oxygen Standers Therapy Services Occupational Therapy Physical Therapy Speech/Language Therapy  
(B) Member Information Section  
Item 4  Member’s Name, Address, and Tel. No.  Enter the member’s name, address, and phone number (including area code).  
Item 13  Explain why this service is medically necessary Diagnosis Code(s) Place of Service Description of Treatment  Enter a statement explaining why the proposed service is medically necessary. Include the primary diagnosis and secondary diagnosis if there is one. Also include a description of the proposed treatment and prognosis. Refer to your MassHealth provider manual for additional information about this field. Enter the ICD-9-CM diagnosis code(s) for the most relevant diagnoses for the procedure or item being requested. Enter the location of service. Enter a narrative of the proposed treatment.  
(C) Services Requested Section  
Item 14  Servicing Provider ID/Service Location or NPI  Enter the nine-digit servicing provider ID followed by the one-character service location code. Write “same” if same as requesting provider ID/Service Location. If not available, enter the provider’s 10-digit national provider identifier.  
Item 15  Service Code  Enter the appropriate CPT or HCPCS code for each service requested. Refer to Subchapter 6 of the applicable MassHealth provider manual to determine payable service codes. You must include a modifier if the service code requires one.  
Item 16  No. of Units  Enter the number of times the service for which you are requesting prior authorization will be furnished. At least “1” must be entered.  
(D) Attachments and Signature  
Item 17  Attachments  Select the “Yes” box if additional information or supporting documentation is attached (refer to your provider manual); otherwise select the “No” box. Be certain that the attached documentation clearly supports the medical necessity for the services and/or equipment you are requesting (for example, X rays, admission notes, photographs, or explicit details).  
Item 21  Provider Signature  The form must be signed by the provider or the individual designated by the provider to certify that the information entered on the form is correct. Signatures other than handwritten (that is, typewritten, or those by stamp or data processing equipment) are acceptable.  
(E) MassHealth Use Only  
Items 22 – 38  Leave these items blank.  MassHealth completes Items 22 – 38 when it reviews the request for prior authorization. Leave these fields blank.  

See Subchapter 5 of your MassHealth provider manual for additional instructions for requesting prior authorization. 
INSTRUCTIONS FOR MAILING REQUESTS FOR PRIOR AUTHORIZATION 
Mail the Prior Authorization Request form, together with all necessary attachments, to: MassHealth ATTN: Customer Service Team For Boston Region, use: P.O. Box 9154 For CCM, use: P.O. Box 9152 For Western Region, use: P.O. Box 9153 Hingham, MA 02043