1. What is the purpose of prior authorization (PA)?
  2. Which services require PA?
  3. How do I submit a request for PA?
  4. What is NewMMIS?
  5. What is the process once the PA request is received?
  6. Who reviews the PA request?
  7. What standard is used when a decision is made?
  8. What are the possible decisions?
  9. Are there time limits that apply to decisions?
  10. How is the consultant's decision communicated?
  11. What if a PA request is deferred?
  12. What if a PA is modified or denied?
  13. Does the member have appeal rights?
  14. Whom can the provider contact to check on the status of a specific PA?
  15. How can I get a provider manual or copies of forms?

1. What is the purpose of prior authorization (PA)?

MassHealth determines the medical necessity of a service or product to be provided to its members through the use of prior authorization (PA) See 130 CMR 450.303. PA determines only the medical necessity of the authorized service and does not establish or waive any other prerequisites for payment (such as a referral or preadmission screening (PAS)). A provider must submit a PA request in accordance with instructions provided by MassHealth for requesting PA in Subchapter 5 of the provider manual.

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2. Which services require PA?

The following categories of services require a PA. To access information about these services, you may click on this link, MassHealth Provider Manuals, to access all MassHealth provider manuals. You may also click on the service categories below to access specific Subchapter 6 Service Code information for each service.

Please note: Dental services are currently administered by Doral.

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3. How do I submit a request for PA?

The process for completing a PA request and submitting the required documentation can be found in Subchapter 5 of your provider manual. To reduce the likelihood of a PA request being deferred or denied, it is essential that the PA request form is completed properly and that the necessary attachments are included with the request. Providers are encouraged to send their PA requests to MassHealth online via the Provider Online Service Center. PA requests and attachments submitted on paper should be mailed to:

  • P.O. Box 9152 - CCM Prior Authorization [Region 31]
  • P.O. Box 9153 - Western MA Prior Authorization [Region 32]
  • P.O. Box 9154 - Boston Prior Authorization [Region 33]

Hingham, MA 02043

PAs submitted for an MCB member should be sent to the Boston region: P.O.Box 9154.

The PA request form is available on the Provider Online Service Center. Additional MassHealth-generated proprietary attachments will be placed on the site as they are developed. When submitting a PA request for certain services, the provider may also be required to submit a provider-specific form (for example, an invoice) along with any MassHealth proprietary attachments. Please consult your provider manual for specific requirements.

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4. What is NewMMIS?

On May 26, 2009, MassHealth launched its New Medicaid Management Information System (NewMMIS) which includes the prior authorization functionality. Providers can easily access the system through the Internet to submit prior authorization requests and attachments electronically. Attachments that consist of photographs or X rays can be submitted electronically, as long as the image is digital. NewMMIS will assign a tracking number to the PA submission. The tracking number (known as GAN number under APAS) is used for tracking purposes only, and consists of nine characters (the tracking number is not the prior authorization number, which consists of one letter followed by nine numbers). While the tracking number is available to the provider immediately, the PA number will not be available until a decision on the PA request has been made.

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5. What is the process once the PA request is received?

Providers may submit PAs either online or on paper. Online submission is strongly encouraged. If submitted online, the system performs validation checks to ensure that required fields are completed and certain minimum information such as provider ID, member ID, procedure code, and dates are included and are valid. PAs submitted on paper are keyed into NewMMIS by PA staff and the system performs similar checks. In both cases, the PA is also stamped with the receipt date. The PA is then forwarded to the appropriate consultant for review and decision. After a decision is made, decision letters are mailed to both the provider and the member.

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6. Who reviews the PA request?

Consultants with education and experience in the service area review the PA form and supporting documentation. These clinical reviewers include physicians, nurses, and therapists. For example, requests for physical therapy services are reviewed by physical therapists, etc.

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7. What standard is used when a decision is made?

The standard is medical necessity. MassHealth will not pay a provider for services that are not medically necessary. A service is medically necessary if:

(1) it is reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the member that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a handicap, or result in illness or infirmity; and

(2) there is no other medical service or site of service, comparable in effect, available, and suitable for the member requesting the service, that is more conservative or less costly to MassHealth. Medically necessary services must be of a quality that meets professionally recognized standards of health care and must be substantiated by records including evidence of such medical necessity and quality.

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8. What are the possible decisions?

The consultants may make any of the following decisions on a PA request:

  • Approve the request - the request is authorized.
    Deny the request - the request is denied and MassHealth will not reimburse for the service.
  • Modify the request - the approval is for a service that is different in quantity or nature than that which was originally requested, but it was determined that the approved item is appropriate to meet the medical needs of the member.
  • Defer the request - the request cannot be adjudicated as additional information is needed to make a decision; the provider is asked to submit supporting documentation.

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9. Are there time limits that apply to decisions?

MassHealth is required to respond to appropriately completed and submitted requests for PA within the following time periods, in accordance with 130 CMR 450.303(A):

  • independent nursing - within 14 calendar days after the date the PA unit receives the request;
  • DME - within 15 calendar days after the date the PA unit receives the request;
  • for all other services (excluding pharmacy and transportation) - within 21 days after the date the PA unit receives the request.

If a PA is deferred, the adjudication clock stops. Both the provider and member are notified that the PA has been deferred. When the provider submits the additional information to MassHealth, the clock starts again from where it left off.

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10. How is the consultant's decision communicated?

Once a decision is made, a notice is sent to the provider through the provider's preferred method of communication and a notice is mailed to the member. The notice advises both parties of the decision and the rationale for the decision. After the decision process is completed, photographs and X rays submitted with the request are returned to the provider. The PA unit does not retain copies of these items. When a PA is submitted via the Provider Online Service Center, the decision can be viewed via the same application. In this way, the provider is aware of the decision in advance of receiving notification via mail, if mail is the provider's preferred method of communication.

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11. What if a PA request is deferred?

If a PA is deferred, notification is sent to both the provider and member, explaining the reason for the deferral; typically missing documentation. The provider may submit the additional information needed, either by mail or by attaching it electronically to the online PA request. Once the additional information is received by the PA unit, review and adjudication can continue. Providers have 30 days to respond to a deferral.

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12. What if a PA is modified or denied?

If a PA request is modified or denied, the member has a right to appeal. Decision letters detailing the reason for the modification or denial are sent to the provider and the member and an explanation of the member's right to appeal and how to appeal are provided to the member with their packet.

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13. Does the member have appeal rights?

The right to appeal the decision made on a PA request belongs to the member. Whenever a PA request is approved, modified, or denied, a letter is sent to the member explaining the decision and providing the reason the decision was made. Also included in the letter is information explaining the member's appeal rights. MassHealth's Board of Hearings is the entity that hears appeals. If needed, interpreter services and/or assistive devices are available to members during the hearing. For questions about the appeals process, call 1-800-862-8341 or 617-727-5550.

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14. Who can the provider contact to check on the status of a specific PA?

If 21 days without response from MassHealth has elapsed since the PA was submitted, providers who sent their PA request on paper may call MassHealth Customer Service at 1-800-841-2900 to check on the status of the PA. Providers who submit their request via NewMMIS can simply go online to determine the status of their request.

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15. How can I get a provider manual or copies of forms?

To request a provider manual or PA forms, call MassHealth Customer Service at 1-800-841-2900, fax to 617-988-8973, e-mail to publications@mahealth.net, or write to the following address. Forms can also be downloaded from the www.mass.gov/masshealth/newmmis.

MassHealth Customer Service
ATTN: Forms Distribution
P.O. Box 9118
Hingham, MA 02043

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Glossary of PA Terms:

NewMMIS terminology

Adjudicated - MassHealth has made a decision on the PA. A notice is sent to the provider through the provider's preferred method of communication and a notice is mailed to the member. The notice describes the results of the adjudication.

Approve - authorization to perform/provide services is granted.

Attachment - documentation accompanying the PA request, which establishes the reason that the service requested is medically necessary. It may also establish the cost of the requested item/service. Attachments may include, but are not limited to: a letter of medical necessity, a prescription, an invoice, a growth chart, etc. Specific required attachments are determined by the service being requested.

Consultant - a clinical professional educated and having experience in a specific clinical field, such as nursing, medicine, or physical therapy.

Defer - adjudication of the PA request is halted due to lack of sufficient documentation to render a decision. Adjudication continues once the provider submits the additional documentation.

Deny - the request for payment of the service is denied.

Medical necessity - A service is medically necessary if:

(1) it is reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the member that endanger life, cause suffering or pain, cause physical deformity or malfunctions, threaten to cause or to aggravate a handicap, or result in illness or infirmity; and

(2) there is no other medical service or site of service, comparable in effect, available, and suitable for the member requesting the service, that is more conservative or less costly to MassHealth. Services that are less costly MassHealth include, but are not limited to, health care reasonably known by the provider, or identified by MassHealth pursuant to a prior-authorization request, to be available to the member through sources described in 130 CMR 450.317(C), 503.007, or 517.007. Medically necessary services must be of a quality that meets professionally recognized standards of health care and must be substantiated by records including evidence of such medical necessity and quality.

Modify - the approval is for a service or product other than what was requested; but it has been determined that the approved item is appropriate to meet the medical needs of the member.

PA number - the number assigned to a PA after it has been reviewed by a consultant and a decision has been made. The PA number is 10 characters long, and is constructed as follows.

PYYJJJNNNN
P = Prior Authorization
YY = the Year
JJJ = Julian date
NNNN = four digit sequence

Tracking Number - a nine-digit number assigned by NewMMIS to a PA request that has been keyed in the system. The tracking number can be used by the provider to ascertain the status of the PA request while it is in process; i.e., not yet adjudicated. Upon adjudication, the provider is notified of the decision and the Prior Authorization number is made available.

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This information is provided by MassHealth. aply