The MassHealth Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information MassHealth needs to determine medical necessity for certain products and services that require prior authorization. MassHealth developed these Guidelines and their associated forms via an ongoing process that includes a rigorous review of the most current evidence-based literature and input from clinical and program staff, and often from external clinical experts.
Members Affected by MassHealth's Guidelines
These Guidelines apply to members enrolled in MassHealth fee-for-service programs, the Primary Care Clinician (PCC) Plan, and in some instances, MassHealth-contracted managed care organizations (MCOs). Providers serving members enrolled in MassHealth-contracted MCOs (currently Neighborhood Health Plan, BMC HealthNet Plan, Network Health, and Fallon Community Health Plan), Senior Care Options (SCO), or Program of All-inclusive Care for the Elderly (PACE) should refer to the health plan's medical policies for covered services. To determine which guidelines apply to your patients enrolled with MassHealth MCOs, SCO, or PACE, please contact the appropriate MassHealth health plan.
Purpose of Guidelines
The Guidelines and their associated forms are intended to clarify the specific medical information that MassHealth needs to determine medical necessity. They are not intended to replace or supersede program regulations. Over time, MassHealth will publish Guidelines for a number of products and services that require prior authorization. Each set of Guidelines has links to supporting information, such as product-specific or service-specific Medical Necessity Review forms and the MassHealth Automated Prior Authorization System (APAS) . These Guidelines may be downloaded and printed.
Note to MassHealth Members: This document was prepared for medical professionals to assist them in submitting documentation supporting the medical necessity of proposed treatment. Some language used in this communication may be unfamiliar to other readers; in this case, contact your health care provider for guidance or explanation.
Sign up for E-mail Alerts
Since evidence-based clinical standards and medical practices are advancing at a rapid rate, MassHealth will update the Guidelines as necessary. To receive notice of updates to the Guidelines and the availability of related forms, you can sign up for e-mail alerts.
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If you have questions or comments about the MassHealth Guidelines for Medical Necessity Determination, call MassHealth Customer Service 1-800-841-2900, send an e-mail to firstname.lastname@example.org, or send a fax to 617-988-8974.
This information is provided by MassHealth.