PCA Prior Authorization Adjustment Form

Increase 
Decrease 

PCA Consumer MassHealth ID No. PCM Agency PA No. 

Current Authorization Requested Authorization Total adjustment 
request 

Specify 
activity ADL/ 
IADL 
PCA time in 
minutes 
Frequency
Times per 
day 
Days per 
week 
Total minutes 
per week 
currently 
authorized 
PCA time in 
minutes 
Frequency
Times per 
day 
Days per 
week 
Total minutes 
per week 
currently 
authorized 
Requested minutes 
per week minus 
current minutes 
per week 
Comments 


Total requested adjusted weekly day/evening PCA hours 

Specify number of hours currently authorized per night
Specify activity ADL/IADL
PCA time in minutes
Frequency
Times per night
Nights per week
Total billable hours per night 
PCA time in minutes
Frequency
Times per night
Nights per week
Total billable hours per night
Requested billable hours per night minus current billable hours per night
Comments









Total requested adjusted billable hours per night 

Is consumer receiving or about to receive any home-based services? 
yes
no 

If “yes,” list additional services: 


PCA-PAAF-1 (01/07) 

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PCA Prior Authorization Adjustment Form (cont.)


Section 1: Additional Comments (to be filled out by PCM agency) 

Additional comments (Attach additional sheets and supporting 
documentation as necessary): 


I have reviewed this adjustment request with the consumer 
Review date: _____________ 

I have reviewed this adjustment request: 
in person/over the telephone (circle one)

Signature of Requesting PCM Agency Reviewer Title Date 

Section 2:  Hours Requested (to be filled out by PCM agency)

Requesting an adjustment from (Check and complete all that apply.)

___________ hours to ___________ day/evening hours per week
___________ hours to ___________ day/evening hours per week
______________ (date) to ___________ (date)

A cover letter must include the reason for the adjustment request.
Specify what has changed for the consumer and how this change impacts the need for physical assistance with ADLs or IADLs.

 
Section 3: Physician/Nurse Practitioner Signature/Comments 

Section 3 must be completed by the consumer’s physician or nurse practitioner in lieu of a letter of medical necessity from the physician or nurse practitioner.

Requesting an adjustment from (Check and complete all that apply).

___________ hours to __________ hours per night 
___________ hours to ___________ day/evening hours per week 


Physician or nurse practitioner comments (attach additional 
sheets as necessary): 

I have reviewed and agree with this request for an adjustment in this consumer’s authorized number of hours of PCA services. The adjustment is a result of changes in the consumer’s condition and/or functional status or a change in living condition that affects the consumer’s ability to perform ADLs/IADLs without physical assistance.

Signature of Physician or Nurse Practitioner Date 

Print physician or nurse practitioner name, address, and telephone number: 


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