Referrals
Referrals are required for certain specialty services in both the PCC plan and Primary Care ACOs [see 130 CMR 450.118(J) and 130 CMR 450.119 (l)]. The requirements for referrals for all other plans are subject to the requirements of the health plan in which the member is enrolled. For specific instructions on how to submit, update, or inquire about a referral, please see the MassHealth POSC Job Aids.
Referral Circles
Primary Care ACOs use the MassHealth Fee-for-Service (FFS) provider network for specialty services and have the option of defining a Referral Circle, a subset of the MassHealth FFS network for whom referral requirements are waived for members in the Primary Care ACO. If a member’s hospital or specialist is part of the Referral Circle of the member’s Primary Care ACO, the member does not need a referral to receive services from that hospital or specialist. Accountable Care Partnership Plans and MCOs may have preferred networks within their overall networks that have modified authorization requirements. For more information on these potential arrangements, please contact the plans directly.
Prior Authorization (PA)
In certain instances, MassHealth requires providers to obtain prior authorization (PA) to provide medical services. These instances are identified in the billing instructions, program regulations, associated lists of service codes and service descriptions, provider bulletins, and other written issuances from MassHealth. Such information, including but not limited to the MassHealth Drug List, is available on the Prior Authorization for MassHealth Providers web page, and copies may be obtained upon request. The provider must submit all prior authorization requests in accordance with MassHealth’s instructions. Prior authorization determines only the medical necessity of the authorized service and does not establish or waive any other prerequisites for payment, such as member eligibility or resort to health insurance payment.
There are two types of PA requests: prior authorization for a drug or nonpharmacy services.
Learn more about Prior Authorization (non-LTSS providers); Or refer to our Job Aids.
LTSS providers can learn more at the LTSS Provider Portal.
Preadmission Screening (PAS)
MassHealth requires screening of inpatient admissions for Acute Inpatient and Chronic Disease and Rehabilitation Hospitals. MassHealth conducts reviews before elective admissions (admission screening) and after discharge but before payment (prepayment review). MassHealth also conducts utilization reviews of inpatient admissions and outpatient services on a post-payment basis pursuant to 130 CMR 450.237. Providers can submit PAS requests through the POSC. PAS determines only the medical necessity of the authorized service and does not establish or waive any other prerequisites for payment, such as member eligibility or resort to health-insurance payment. For specific instructions on how to submit, update, or inquire about a PAS, please see the MassHealth POSC Job Aids.
Non-Emergency Medical Transportation (PT-1)
MassHealth provides non-emergency medical transportation for both ambulatory and non-ambulatory MassHealth members living in the community who are going to MassHealth-covered services.
Chair van/chair car transportation is provided through a PT-1 form. This form must be completed for authorization to transport a member to a specific location. MassHealth members will need a separate form for each location or service that they need to go to. Please submit a PT-1 form online through the Customer Web Portal (CWP) to obtain transportation services for your patient. We no longer accept PT-1 forms by fax or mail.
It is the responsibility of the provider to verify eligibility, and coverage of the individual needing transportation, before a PT-1 request is submitted, and/or before coordinating Ambulance (non-emergency) transportation with an ambulance provider directly.
Learn more information about the PT-1 form and the Customer Web Portal.
Prior Authorizations for Durable Medical Equipment (DME) and Oxygen/Respiratory
Prior authorization requirements for DME/OXY can be found on our MassHealth Durable Medical Equipment and Oxygen Payment and Coverage Guideline Tool.
Prior Authorizations for Orthotics and Prosthetics (ORT/PRT)
Prior authorization requirements for ORT/PRT can be found in the MassHealth Orthotics and Prosthetics Payment and Coverage Guideline Tool.
Learn more about prior authorization and view the MassHealth Guidelines for Medical Necessity Determination.
All non-LTSS providers submit PA requests through the POSC. Please view the Job Aid.
All LTSS providers submit PA requests through the LTSS Provider Portal. Please view the PA training and resources under Provider Resource in the LTSS Provider Portal.
Photo: Thisisengineering, Unsplash
| Date published: | July 29, 2022 |
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