Part 2. Prior Authorization 
MassHealth requires providers to obtain prior authorization (PA) for certain services. See the 
MassHealth program regulations for the proposed service to determine when PA is required. In addition 
to program regulations, PA requirements may appear in Subchapter 6 of certain provider manuals, 
provider bulletins, or in other written issuances from MassHealth. MassHealth posts its publications in 
the Provider Library on the MassHealth Web site at www.mass.gov/masshealth. Click on MassHealth 
Regulations and Other Publications, then on Provider Library. To identify which drugs require PA, go 
to the MassHealth Drug List at www.mass.gov/druglist. 
MassHealth reviews PA requests on the basis of medical necessity only and does not establish or waive 
any other prerequisites for payment, including eligibility or referral. The approval of a PA is not a 
guarantee of payment. You must still verify the member’s eligibility, other insurance, and any other 
restrictions before providing service. If PA is required for a service that you want to provide, follow 
these guidelines when submitting your request to MassHealth. 
The following information and instructions about PA are for:
*	non-pharmacy services;
*	pharmacy services; and
*	nonemergency transportation services.
Requesting Prior Authorization for Non-pharmacy Services 
For non-pharmacy medical services, MassHealth strongly encourages providers to request PA using the 
Provider Online Service Center (POSC) at www.mass.gov/masshealth/providerservicecenter. Providers 
can use the POSC to submit PA requests and all attachments electronically and to review the status of 
PA requests.
Providers may also request PA for non-pharmacy services using the paper Prior Authorization Request 
form (PA-1). The PA-1 form and attachments should be sent to the appropriate address listed on the PA 
form or in Appendix A of your MassHealth provider manual.
*	PA requests for members of the Massachusetts Commission for the Blind (MCB) will be handled 
by the Prior Authorization unit. These PAs can also be submitted via the POSC.
*	If the PA request is for a member of Community Case Management (CCM), CCM will process the 
request, which can be submitted via the POSC;
*	If the PA request is for dental services, a third-party administrator processes the request. This 
request must be submitted on the ADA dental claim form, not the PA-1 form.
For any subsequent request for the same service, you must request a new PA. Subsequent requests may 
be submitted via the POSC. If you choose to complete a paper PA request, mail it along with a copy of 
the initial request and any required supporting documentation to the appropriate address listed in 
Appendix A of your MassHealth provider manual.
For address and telephone information for non-pharmacy PA services, refer to Appendix A of your 
MassHealth provider manual.
Other Required Prior Authorization Forms 
PA requests for certain services require additional forms that must accompany the request. These 
supplemental forms (attachments) may be submitted via the Provider Online Service Center, along with 
the paper PA form, or on the ADA form for dental requests.
Dental Services
*	Supplemental Dental Prior Authorization Form 
The supplemental dental prior authorization form (DEN-1) is a two-sided form on which the 
provider charts the current status of the member’s teeth. This form must accompany the PA 
request for all dental services except orthodontics. This form may be submitted as an 
attachment via the POSC or as an attachment submitted with the paper PA form.
*	Orthodontics Prior Authorization Form 
For full orthodontic treatment and treatment visits that are billed quarterly, the orthodontist 
must complete an orthodontics prior authorization form (DEN-2). This form may be submitted 
as an attachment via the POSC or as an attachment submitted with the paper PA form.
For continuation of orthodontic services for the second year, the orthodontist must submit a 
new PA request with updated information and a copy of the original orthodontic prior 
authorization form (DEN-2). The same procedure must be used for the first half of the third 
year, if this treatment is necessary. 
*	Peer Assessment Rating Index (PAR Index Recording Form) 
Orthodontists must complete the PAR Index Recording Form (DEN-7) when requesting PA for 
full orthodontic treatment (see 130 CMR 420.428(H) in the dental regulations). This form may 
be submitted as an attachment via the Provider Online Service Center or as an attachment 
submitted with the paper PA request form. Refer to Appendix D of the Dental Manual for 
detailed instructions and examples of the use of the PAR Index Recording Form.
Nursing Services 
*	Request and Justification for Continuous Skilled Nursing Services 
When requesting PA for continuous skilled nursing services for members over the age of 21, 
the provider must complete both a PA-1 form and a request and justification for continuous 
skilled nursing services (PA/PDN-1). This form may be submitted as an attachment via the 
POSC or as an attachment submitted with the paper PA form.
If the member is under the age of 22, PA requests must be obtained from Community Case 
Management (CCM). Direct your requests to the appropriate address provided in Appendix A 
of your MassHealth provider manual.


Therapy Services: Physical, Occupational, and Speech/Language 
*	Request and Justification for Therapy Services 
When requesting PA for therapy services, the provider must complete both a PA-1 form and a 
request and justification for therapy services form (THP-2). 
If the member is under the age of 22, PA requests must be obtained from CCM. Direct your 
request to the appropriate address in Appendix A of your MassHealth provider manual.
Obtaining Forms 
You may download PA forms from www.mass.gov/masshealth, by clicking on the MassHealth Provider 
Forms link. You may also request supplies of all PA forms from the appropriate address listed in 
Appendix A of your MassHealth provider manual. 
Notice of Prior Authorization Decision for Non-pharmacy Services 
MassHealth notifies both the provider and the member in writing, of its decision on PA requests. The 
letter indicates whether the services were approved, modified, or denied. The letter also contains the PA 
number assigned to the request, even if the request was denied. If the service was approved or modified, 
you must include the PA number on the claim when submitting it for payment. If you have submitted 
your PA request via the POSC, you can also find out the status of your request using the same service. 
MassHealth responds to PA requests that contain all required information within the time periods 
specified in 130 CMR 450.303(A):
*	Nursing – within 14 calendar days from the date the PA unit receives the request;
*	DME – within 15 calendar days from the date the PA unit receives the request; and
*	For all other services – within 21 days from the date the PA unit receives the request.
Prior Authorization Decisions for Non-pharmacy Services
MassHealth may make any of the following decisions on a PA request.
Note: See PA notice for decision on a PA request.
*	Approve the request – the request is authorized.
*	Modify the request – the authorization is for a service or item that is different in quantity or nature 
than that which was originally requested.
*	Deny the request – the request is denied and MassHealth will not pay for the service.
*	Defer the request – the PA is returned to the provider with a request for additional information and 
status of “deferred,” that must be submitted before a decision can be made. If the deferral is via the 
POSC, the screen is titled “Additional Information.”


Requesting Prior Authorization for Pharmacy Services 
For pharmacy services, MassHealth encourages providers to request PA using a drug-specific PA form, 
if applicable, or the MassHealth drug prior authorization request form. All PA forms for pharmacy 
services, along with the MassHealth Drug List, are available on the Web at www.mass.gov/druglist. All 
PA requests for drugs must be submitted by mail or faxed to the address or fax number listed on the PA 
form or listed in Appendix A of your MassHealth provider manual.
Notice of Prior Authorization Decision for Pharmacy Services 
The Drug Utilization Review (DUR) program notifies the pharmacy, the provider, and the member, in 
writing, of its decision within 24 to 48 hours of the date the DUR program receives the request. A fax is 
sent to the pharmacy and the provider, and the member receives a letter. The PA number is provided on 
the fax only if the request is approved. The pharmacy provider should not enter this number on the 
online transaction. A PA tracking number is assigned regardless of whether the request was approved or 
denied.
Requesting Prior Authorization for Non-emergency Transportation 
For nonemergency transportation services, the provider of the medical service for which the member 
needs transportation must fill out the Prescription for Transportation (PT-1) form to verify that the 
member's need for transportation is medically necessary. The request for transportation is approved 
only when public and private transportation resources are not available and door-to-door transportation 
is medically necessary. Providers must send completed PT-1 forms to the appropriate address listed in 
Appendix A of their MassHealth provider manual. See the MassHealth transportation regulations for 
more information about MassHealth coverage for nonemergency transportation services. PT-1 forms 
are processed within four business days from receipt. 
Notice of Prior Authorization Decision for Transportation Services
Transportation authorization specialists may take any of the following actions on a request (PT-1).
*	Authorize the request – the request is approved and MassHealth will pay for the service.
*	Deny the request – the request is denied and MassHealth will not pay for the service.
*	Mail back the request – the form is incomplete and is being returned to gather missing 
information.


Commonwealth of Massachusetts 
MassHealth 
Provider Manual Series
Subchapter Number and Title
5. Administrative and Billing 
Instructions
Page
5.2-1
All Provider Manuals
Transmittal Letter
ALL-165
Date
05/26/09