MassHealth Application 

to Request Prior Authorization for PCA Services 


THE COMMONWEALTH OF MASSACHUSETTS 

Executive Office of Health and Human Services 

Personal care management (PCM) agencies must complete this application in full 
when requesting prior authorization (PA) for PCA 
services, and submit it via the MassHealth Provider Online Service Center (POSC) 
along with the completed and signed MassHealth PCA 
Evaluation form (PCA-2) or the MassHealth PCA Reevaluation (No Change) form 
(PCA-R), as appropriate. Include all relevant supporting 
documentation and attach a separate sheet if needed. 

Note: Section VII does not need to be completed if the PA request is for the 
same number of PCA hours authorized at the start 
date of the PA, and the 3rd box below is checked. 

Check one: 


(1: 1) Unchecked
Initial evaluation 
(1: 2) Unchecked
Reevaluation for consumer (change in PCA hours since start date of current PA) 
(1: 3) Unchecked
Reevaluation for consumer (no change in PCA hours since start date of current 
PA) 


SECTION I: Personal Care Management (PCM) Agency 

PCM agency name: PCM ID no.: 
(text) 
(text) 


SECTION II: Consumer Information 

Consumer name and address: 
(text) 


Birth date: Age: Date of evaluation: MassHealth ID no.: 
(text) 
(text) 
(text) 
(text) 


Does the consumer have a legal guardian? . . . . . . . . . . . . . . . . . . . . 
. . . . . . . . 


(1: not applying) Unchecked
Yes 
(1: Applying) Unchecked
No 
If yes: Consumer’s legal guardian’s name and address and telephone number: 
(text) 



(1: 1) Unchecked
Site of in-person evaluation (Check one and provide address and name of facility 
if applicable.): 
(text) 
Home Address:


(1: 2) Unchecked
(text) 
Nursing facility (NF) Address:
(1: 3) Unchecked
(text) 
Hospital Address:
(1: 4) Unchecked 
Other (describe): 
Address: 
(text) 
(text) 


Note: MassHealth cannot pay for PCA services provided while the consumer is in a 
nursing facility or other inpatient facility. Include 
(text) 
discharge date for consumers in a facility at time of evaluation: 
_____________________________________ 

Address for service delivery: 
(text) 


Date of initial referral to PCM agency: 

 Referral source: 
(text) 
(text) 


For new applicants, the event(s) that precipitated the request for PCA services: 
(text) 


Living arrangements (Check one.): 


(1: 1) Unchecked 
Lives with family 
Lives independently 
(1: 3) Unchecked
Assisted living 
Nursing facility 
(1: 5) Unchecked
Transitional living 
(1: 2) Unchecked
(1: 4) Unchecked
State/federal funded residential supports (Check one, if applicable.): 

 
MassHealth Group Adult Foster Care (GAFC) 

 
MassHealth Adult Foster Care (AFC) 
Dept. of Developmental Services (DDS) residential support (less than 24/7) 
(1: 1) Unchecked
(1: 4) Unchecked 
Dept. of Children and Families (DCF) foster care 
Dept. of Mental Health (DMH) residential 
(1: 2) Unchecked
(1: 3) Unchecked
(1: 6) Unchecked 
Mass. Rehabilitation Commission (MRC) residential 
(1: 7) Unchecked 
Rest Home 
Other state funded (describe): 
(1: 5) Unchecked
(1: 8) Unchecked
(text) 
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PCA-1 (Rev. 10/10) 




Consumer Name 
(text) 


Lives with (Check all that apply.): 


(1) Unchecked
Mother 
Father 
(1) Unchecked 
Spouse 
Siblings(number and age: _________________________________________ ) 
Other caregiver
(1) Unchecked
(1) Unchecked 
Children (number and age: ______________________________ ) 


(1) Unchecked
(text) 
(text) 
Alone 
(1) Unchecked 
Other family members 
Other (describe: _________________________________________________ ) 
(1) Unchecked
(1) Unchecked
(text) 
Roommates (number and age: ___________________________ ) 
(text) 
(1) Unchecked
(1) Unchecked


Is anyone else in the home receiving MassHealth PCA services? . . . . . . . . . 
. . . . . . . 
(text) 



(1: not applying) Unchecked
Yes 
(1: Applying) Unchecked
No 
If yes, list names of other persons receiving MassHealth PCA services: 

Are individuals in the home currently providing personal care to consumers? . . 
. . . . . . 


(1: not applying) Unchecked
Yes 
(1: Applying) Unchecked
No 
If yes, explain why caregiver cannot continue to provide care. For example, the 
caregiver has been diagnosed with a terminal illness. 
Has consumer received PCA services from MassHealth in the past? . . . . . . . . 
. . . . . . 


(1: not applying) Unchecked
Yes 
(1: Applying) Unchecked
No 
If yes, identify the following: 
PCM agency: PA no: Dates of service: 
(text) 
(text) 
(text) 


SECTION III: Consumer PCA Schedule 

Current PCA schedule (weekdays/weekends): 
(text) 


Current PA no.: Current authorization: day/evening hours/week Current night 
hours per night: Expiration date: 
(text) 
(text) 
(text) 
(text) 


Day/evening PCA hours being requested per week: Night hours being requested per 
night: 
(text) 
(text) 


SECTION IV: In-Home Services 

Is the consumer receiving or about to receive any other services in his or her 
home? . . . 


(1: not applying) Unchecked
Yes 
(1: Applying) Unchecked
No 
If yes, check all applicable boxes below, enter dates of service or projected 
start date, and describe the services being provided. 
a) 
Home health 
(text) 
(text) 



(1: not applying) Unchecked
Yes 
(1: Applying) Unchecked
No 
Name of agency: 

Dates of service or start date: 

Service type (nursing; home health aide, etc.): 

Number of hours: 
(text) 
(text) 


Schedule: 
(text) 
(text) 


Telephone: 

b) 
Continuous skilled nursing (private duty nurse) 
(text) 
(text) 



(1: not applying) Unchecked
Yes 
(1: Applying) Unchecked
No 
Name of agency: Dates of service or start date: 
Number of hours: 
(text) 
(text) 
(text) 


Schedule: 

Telephone: 

c) 
Respite 
(text) 
(text) 



(1: not applying) Unchecked
Yes 
(1: Applying) Unchecked
No 
If yes, identify funding source: 
Name of agency: 

Dates of service or start date: 
(text) 
(text) 
(text) 
(text) 


Number of hours: 

Schedule: 

Telephone: 

d) 
Elder services Yes No 
Name of agency: 
(text) 
Contact: 
(text) 
Telephone: 
(text) 
Dates of service or start date: 
(text) 
Service type(s) (homecare, chore service, meals on wheels, etc.): Number of 
hours: 
(text) 
(text) 



(1: not applying) Unchecked
(1: Applying) Unchecked
Schedule: 
(text) 



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Consumer Name 
(text) 


e) 
DDS contracted (respite care, family support, day program, etc.) 
Name of agency: 
Telephone: 
Service type(s) (nursing, hospice aide, etc.): 
Schedule: 
(text) 
(text) 
(1: not applying) Unchecked
(text) 
(text) 
Yes No 
Contact: 
Dates of service or start date: 
(text) 
(text) 
(1: Applying) Unchecked
Number of hours per week 
(text) 
f) 
MRC contracted 
Name of agency: 
Telephone: 
Schedule: 
(1: not applying) Unchecked
Yes 
(1: Applying) Unchecked
No 
(text) 
(text) 
Contact: 
Dates of service or start date: 
(text) 
(text) 
(text) 
g) 
Hospice Yes 
Name of agency: 
Telephone: 
(1: not applying) Unchecked
Schedule: 
No 
(1: Applying) Unchecked
(text) 
(text) 
Contact: 
Dates of service or start date: 
(text) 
(text) 
(text) 
h) 
Other in-home services (describe) 
(text) 


SECTION V: Out–of–Home Activities 

Does the consumer participate in any other activities outside his or her home?. 
. . . . . . 


(1: not applying) Unchecked
Yes 
(1: Applying) Unchecked
No 
If yes, check all applicable boxes and complete the information below, including 
a description of the activities. 
a) 
Adult day health 


(1: not applying) Unchecked
Yes 
(1: Applying) Unchecked
No 
Program: 
(text) 


Contact: 
(text) 


Telephone: 

Dates of service or start date: 
(text) 
(text) 


Schedule: 
(text) 


b) 
Day habilitation Yes 
(1) Unchecked
No 
(1) Unchecked
Program: 
(text) 
Contact: 
(text) 
Telephone: 
(text) 
Dates of service or start date: 
(text) 
Schedule: 
(text) 


c) 
DMH contracted services 
Program: 
Telephone: 
Schedule: 
Yes 
(1: not applying) Unchecked
No 
(text) 
(text) 
(text) 
(1: Applying) Unchecked
Contact: 
Dates of service or start date: 
(text) 
(text) 
d) 
DDS contracted services (respite care, family support, day program, etc.) 
Program: 
Telephone: 
(text) 
(text) 
Schedule: 
Yes No 
Contact: 
Dates of service or start date: 
(text) 
(text) 
(1: not applying) Unchecked
(1: Applying) Unchecked
(text) 
e) 
School Yes No 
Ch. 766-Special Education Program: 
Telephone: 
(text) 
(text) 
(1: not applying) Unchecked
(1: Applying) Unchecked
Schedule: 
Contact: 
Dates of service or start date: 
(text) 
(text) 
(text) 



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Consumer Name 
(text) 
f) 
MRC contracted services 
Program: 
Telephone: 
Schedule: 
(text) 
(text) 
(1: not applying) Unchecked
(1: Applying) Unchecked
Yes No 
Contact: 
Dates of service or start date: 
(text) 
(text) 
(text) 
g) 
Employment Yes 
Place of employment: 
Telephone: 
(1: not applying) Unchecked
(1: Applying) Unchecked
Schedule: 
No 
Contact: 
Dates of service or start date: 
(text) 
(text) 
(text) 
(text) 
(text) 
h) 
Early Intervention: 
Program: 
Telephone: 
Yes 
(1: not applying) Unchecked
No 
(1: Applying) Unchecked
Contact: 
Dates of service or start date: 
(text) 
(text) 
(text) 
(text) 


Service type (occupational therapy, physical therapy, OCC therapy, nursing, 
etc.) 
(text) 


Schedule: 
(text) 
i) 
Other out-of-home activities: 
Program: 
Telephone: 
(text) 
(text) 
(1: not applying) Unchecked
(1: Applying) Unchecked
Yes No 
Contact: 
Dates of service or start date: 
(text) 
(text) 


Service type: 
(text) 


Schedule: 
(text) 


This section must be completed by the PCM agency’s RN. 
SECTION VI: Diagnosis (Primary diagnosis affecting functional status and 
warranting PCA services) 

What is the chronic condition(s) that prevents the consumer from performing his 
or her activities of daily living (ADLs) and instrumental activities of daily 
living (IADLs) without physical assistance? (List all conditions.): 
(text) 


Date of onset:
(text) 
(text) 
(text) 


 
Current height:

 
Current weight: 

SECTION VII: Medical History 

List consumer’s medical history relevant to application for PCA services, such 
as changes in the consumer’s medical condition from 
previous year’s evaluation, diagnoses, hospitalizations, and surgical procedures 
and attach any recent documentation, such as discharge 
summaries, home health care plan (485), etc., that further describes the 
consumer’s functional abilities and limitations. Attach a separate 
sheet if necessary. 

Note: This section does not need to be completed when submitting a PA request 
with no change in PCA hours. 
(text) 



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Instructions for Completing the MassHealth Application to Request Prior 
Authorization for PCA Services 

The following instructions are provided to guide personal care management (PCM) 
agencies in the completion of the MassHealth 
Application to Request Prior Authorization for PCA Services form (PCA-1). PCM 
agencies must complete this application form in full and 
submit it along with the appropriate completed, signed, and dated evaluation or 
reevaluation form via the MassHealth Provider Online 
Service Center (POSC), when requesting prior authorization for PCA services. 
Include any relevant supporting documentation (attach a 
separate sheet if needed). MassHealth may deny or defer the prior authorization 
(PA) request if the application is incomplete. 

Please Note: Section VII does not need to be completed if the PA request is for 
the same number of PCA hours authorized at the start date of 
the PA, and the request is submitted using the Personal Care Agency Reevaluation 
Form (No Change). Enter the consumer’s name in 
the space at the top of each page of the application. 

Instructions for Section I: Personal Care Management (PCM) Agency 

Enter the name and MassHealth provider number of the PCM agency requesting the 
PA. 

Instructions for Section II: Consumer Information 

Consumer name and address: Enter the consumer’s name and address at the time the 
PA request is submitted to MassHealth. If the consumer is 
residing in a nursing facility or other inpatient facility at the time the PA 
request is submitted to MassHealth, state the name and address of the facility, 
and include the projected date of discharge. 

Please Note: MassHealth cannot pay for PCA services while a member is residing 
in a nursing facility or other inpatient facility. 

Birth date: Enter consumer’s date of birth. 
Age: Enter consumer’s age. 
Date of evaluation: Enter the date that the PCM RN conducted the PCA evaluation 
included in this PA request. 
MassHealth ID: Enter the consumer’s MassHealth 12-digit identification number. 
Does consumer have a legal guardian?: Check the appropriate box to indicate if 
the consumer has a legal guardian. If yes, enter the legal guardian’s 
name, address, and phone number. 
Site of evaluation: Check one of the boxes to identify the location where the 
PCA evaluation was conducted in the presence of the consumer (home, 
nursing facility, hospital, or other), and provide the address of the site. 
Address for service delivery: Enter the address where the consumer will be 
receiving PCA services. A P.O. box is not acceptable. 
Date of initial referral to PCM agency: For new consumers only, enter the date 
that the consumer was referred to the PCM agency for PCA services. 
Referral source: For new consumers only, enter the name of the individual who 
referred the consumer to the PCM agency for PCA services. Include the 
individual’s relationship to the consumer and name of organization, if 
applicable. 
Event that precipitated the request for PCA services: For new consumers only, 
state why the consumer is being referred for PCA services at this 
time, including any particular event that led to the referral (such as caregiver 
no longer available to provide care, etc.). 
Living arrangements: Check the box that most accurately describes the consumer’s 
living arrangements. 


Please note the following: 

MassHealth cannot pay for PCA services while a consumer is receiving MassHealth 
group adult foster care (GAFC) or MassHealth adult foster 
care (AFC) services. If a consumer is receiving GAFC or AFC services at the time 
the PA request is submitted, PCM agencies must provide the 
date the consumer will be discharged from GAFC or AFC. If the consumer is being 
discharged from AFC, the PCM agency must include a copy 
of the AFC discharge plan. 

MassHealth can pay for PCA services if the consumer is living in a rest home, if 
the PCA services do not duplicate services the member is 
receiving in the rest home. 

MassHealth is the payer of last resort. If a consumer receives residential 
supports and is also requesting PCA services, PCM agencies must 
include additional supporting documentation that describes the residential 
supports the consumer is receiving. 

Consumers receiving residential support on a 24/7 basis, through the Department 
of Developmental Services (DDS), are not eligible for PCA 
services because DDS provides for all assistance with activities of daily living 
(ADLs) and instrumental activities of daily living (IADLs). 




PA requests for consumers receiving residential support on less than a 24/7 
basis through DDS must include the DDS PCA referral 
documentation as required by the DDS/EOHHS Interagency Service Agreement (ISA). 

PA requests for consumers receiving residential support through other state 
agencies such as the Department of Mental Health (DMH), the 
Department of Children and Family Services (DCF), the Massachusetts Commission 
for the Blind (MCB), or the Massachusetts Rehabilitation 
Commission (MRC) must include a copy of the residential support contract with 
the agency’s vendor. 

Lives with: Check all applicable boxes that describe who the consumer is living 
with. 
Is anyone else in the home receiving MassHealth PCA services?: Check as 
appropriate and, if yes, provide the names of the other PCA consumers. 
Are individuals in the home currently providing personal care to consumers?: 
Check as appropriate to identify if anyone in the consumer’s 


home is providing nonpaid personal care. If yes, explain why the caregiver can 
no longer provide the care. 
Has consumer received PCA services from MassHealth in the past?: Check as 
appropriate. If yes, provide the name of the PCM agency, the PA 
numbers, and the dates of service. 


Instructions for Section III: Consumer PCA Schedule 

Current PCA schedule: Enter the hours and days the consumer currently schedules 
his/her PCAs to work (for example, Sat and Sun 8-10 A.M. and 4-8 

P.M. each day; Mon- Friday 4-8 P.M. each day). The PCA schedule reflects the 
consumer’s daily schedule. For example, a consumer who is at adult day 
health during the weekdays and at home all day on weekends. 
Current PA number, current authorization, day/evening, and night hours, 
expiration date being requested: Enter the information as requested. 


Instructions for Section IV: In-Home Services 

Is the consumer receiving or about to receive any other services in his or her 
home?: Check the appropriate box. If yes, check all applicable 
boxes that describe the other services the consumer receives, or plans to 
receive, in his/her home. Include all information as requested. 
If the consumer is receiving services from a home health agency, attach the 
“485” from the home health agency that describes the services the consumer 
is receiving. If the consumer is receiving hospice services, attach the hospice 
provider’s plan of care for the consumer. 


Please Note: PCA services cannot duplicate services the consumer is receiving 
through another source. 

Instructions for Section V: Out–of–Home Activities 

Does the consumer participate in any other activities outside his/her home?: 
Check the appropriate box. If yes, check all applicable boxes that 
describe the other services the consumer receives, or plans to receive, outside 
his/her home. Include all information as requested. 

Please Note: PCA services cannot duplicate services the consumer is receiving 
through another source. 

Sections VI and VII must be completed by the PCM agency’s registered nurse (RN) 

Instructions for Section VI: Diagnosis 

State the primary diagnosis that affects the consumer’s functional ability to 
perform his or her ADLs and IADLs without physical assistance. List the 
date of onset of this medical condition. Include the member’s current height and 
weight. 

Instructions for Section VII: Medical History 

Please Note: You do not need to complete Section VII if you checked Box 3 at the 
top of page one, and if you are submitting the MassHealth 
PCA Reevaluation Form (No Change) with this PA request. 

Describe consumer’s medical history relevant to this application for PCA 
services, such as changes in the consumer’s medical condition, 
diagnosis, hospitalizations, and surgical procedures since the consumer’s 
previous PCA evaluation. Attach any recent documentation such as 
discharge summaries, home health “485” plan, hospice care plan, etc., that 
describes the consumer’s functional abilities and limitations.