By the Division of Insurance

BULLETIN 2017-04

To:            Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc.,

                  and Health Maintenance Organizations

From:        Gary Anderson, Acting Commissioner of Insurance

Date:         September 11, 2017

Re:            Using Standard Prior Authorization Forms when Reviewing Requests for Hepatitis C Medication, Non-OB Ultrasound and SYNAGIS®


   The Division of Insurance (“Division”) issues this bulletin to inform insured health carriers (“Carriers”) about the use of standard prior authorization forms when reviewing requests for certain medications and imaging services.  Pursuant to M.G.L. c. 176O, §25(c), the Division is mandated to implement health services prior authorization forms. 

     The Massachusetts Collaborative, composed of representatives from insurance carriers, provider groups and associations developed and submitted a series of standard prior authorization forms for use in reviewing requests for the following medications and/or services.  Based on the work of the members of the Collaborative, the group developed the following forms:

  1. Massachusetts Standard Form for Hepatitis C Medication Prior Authorization Requests pdf format of hep-c-form.pdf
  2. Non-OB Ultrasound Authorization Form pdf format of non-ob-form.pdf
  3. Massachusetts Standard Form for SYNAGIS Prior Authorization Requests pdf format of synagis-form.pdf

     The Division held an informational session on February 27, 2017 to collect feedback relavent to the proposed prior authorization forms.  In response to comments provided during the information session, the Massachusetts Collaborative submitted amended forms to the Division on June 15, 2017.  The amended forms as included in the Appendix to this bulletin, are approved by the Division as the standard prior authorization forms for Hepatitis C medication, SYNAGIS®, and non-OB ultrasound services under insured health plans.  Carriers may no longer require the use of any other paper forms other than the standard forms for the aforementioned medications and/or services, which Carriers shall make available for use by all contracted providers.

     By no later than 90 days after the issuance of the bulletin, the Division expects that Carriers take all necessary steps to amend their utilization review systems to accept the attached standard

prior authorization forms.  Providers may submit these forms by mail, as an attachment to electronic mail, or by facsimile machine.  The applicable standard prior authorization forms will serve as sufficient information for Carriers to make their decisions about the medical necessity and appropriateness of the requested medications and/or services.   For providers who use existing forms for prior authorization, Carriers will continue to accept those forms until at least six months after the issuance of this bulletin.

     Six months after the issuance of this bulletin, the Division expects that all Carriers will amend any electronic or internet-based systems used to collect utilization review information, so that those systems will only ask questions as stated in the approved forms in a format and order substantially similar to the format of the approved format.  Carriers wishing to modify the format or order from the standard form are required to submit screenshots of all such forms for the Division’s review before use of the forms in the market.  Data collected electronically by Carriers for prior authorizations should be identical to the data collected on these paper forms.

The Division is aware that Carriers and providers may have differing degrees of readiness for implementing standard prior authorization forms; therefore, the Division is sending this guidance to remind all Carriers of their obligations under federal rules. As the additional paper forms become available, the Division strongly encourages Carriers to take steps to work with provider organizations to educate providers and ensure that all providers use standard prior authorization forms as dictated in this or subsequent guidance. 

     If you have any questions about this Bulletin, please contact Tracey McMillan, Director of Bureau Managed Care at 617-521-7347 or