Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA  02111
www.mass.gov/masshealth	
	MassHealth
	All Provider Bulletin 142
	December 2004

	TO:	All Providers Participating in MassHealth

	FROM:	Beth Waldman, Medicaid Director

	RE:	Guidelines for Medical Necessity Determination for Certain Products and Services 

MassHealth Guidelines	This bulletin is to inform you about a new Web-based resource for
for Medical Necessity	providers.  In December 2004, MassHealth will begin posting on its
Determination	Web site a targeted series of Guidelines for Medical Necessity Determination (Guidelines) and their associated forms for certain products and services.

	MassHealth developed these Guidelines and 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	These Guidelines apply to members enrolled in MassHealth fee-for-
These Guidelines	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.  Services that are available to eligible MassHealth members but are not services currently covered under the member’s health plan are subject to MassHealth Guidelines.  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.

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First Guidelines Being	Guidelines for the following durable medical equipment products will be 
Issued	posted on the MassHealth Web site in December 2004:

•	absorbent products;
•	enteral nutritional products; and
•	support surfaces.

To view these Guidelines on the MassHealth Web site, go to www.mass.gov/masshealth/guidelines.    

Prior Authorization and	Each set of Guidelines has links to supporting information, such as 
Associated Forms 	product-specific or service-specific Medical Necessity Review forms and prior authorization forms located on the MassHealth Automated Prior Authorization System (APAS) Web site.  You can access these documents using any Internet browser.  You can also download and print them.  

Prior Authorization	To obtain paper copies of these Guidelines and associated forms, 
Forms	send a written request to the following address or fax number:

	MassHealth Forms Distribution
	P.O. Box 9101
	Somerville, MA  02145 
	Fax:  703-917-4937

When requesting forms, providers must include their provider number, street address (no post-office boxes), a contact name, the exact name of the form, and the quantity desired.  Please note that these prior-authorization forms can also be found on the APAS Web site at www.masshealth-apas.com. 

E-mail Alerts	Since evidence-based clinical standards and medical practices are advancing at a rapid rate, MassHealth will update these Guidelines as necessary.  Providers should check the Web site frequently, or sign up for e-mail alerts to receive notice of updates to the Guidelines and the availability of related forms.  To sign up for e-mail alerts, go to the Guidelines for Medical Necessity Determination Web page, and click on the link for e-mail alerts.

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Services Requiring 	As a reminder, certain products and services in the following categories 
Prior Authorization	currently require prior authorization:

•	audiology/hearing services
•	dental services
•	durable medical equipment and supplies
•	oxygen and respiratory services
•	personal care attendant services
•	pharmacy services
•	physician services
•	private duty nursing
•	therapy services (occupational therapy, physical therapy, speech and language therapy)
•	vision care services

Other categories that require prior authorization may not be reflected in the above list.  Please consult your MassHealth provider manual to determine which products and services require prior authorization.  Over time, MassHealth will publish Guidelines for additional products and services that require prior authorization.  

Questions	If you have questions or comments about the MassHealth Guidelines for Medical Necessity Determination, call the MassHealth Provider Services Department at 617-628-4141 or 1‑800‑325-5231.