Frequently Asked Questions
1. What is the purpose of prior authorization (PA)?
For certain services or products, MassHealth determines whether the service or product is medically necessary for a member through the use of prior authorization (PA). See 130 CMR 450.303. PA determines only the medical necessity of the authorized service and does not establish or waive any other prerequisites for payment, such as a referral or preadmission screening (PAS). Providers must submit PA requests in accordance with all applicable MassHealth rules and regulations, including but not limited to the PA request instructions in Subchapter 5 of the provider manual.
2. Which services require PA?
The following categories of services require a PA. You can find information about these services in the MassHealth Provider Manuals.
- Adult Day Health (ADH)
- Adult Foster Care (AFC)
- Day Habilitation (DH)
- Durable Medical Equipment
- AAC non-dedicated device
- Absorbent products
- DME-Other
- Enterals
- Mobility and repairs
- Orthotics and prosthetics
- Oxygen
- PERS
- Standers
- Group Adult Foster Care (GAFC)
- Home Health (HH)
- Home Health Aide
- Skilled Nursing Visits
- Medication Administration Visits
- Medical
- Early Intervention Program
- Hearing Instrument Specialist
- Physician Services
- Vision Care
- Personal Care Attendant (PCA)
- Therapy Services
- Occupational therapy
- Physical therapy
- Speech/language therapy
- Pathology therapy
Please note: Dental services are administered by DentaQuest.
3. How do I submit a PA request?
Providers are required to send their PA requests to MassHealth electronically. Paper PA requests will only be accepted if a provider has an approved MassHealth electronic claims waiver.
To reduce the likelihood of a delay in PA adjudication be sure to complete the PA request with the necessary data and attachments.
If you have an approved MassHealth electronic claims waiver, PA requests and attachments submitted on paper should be mailed to:
MassHealth
ATTN: Prior Authorization
100 Hancock Street, 6th Floor
Quincy, MA 02171-1745
The PA request form is available on the POSC. Additional MassHealth-generated proprietary attachments will be placed on the site as they are developed. When submitting a PA request for certain services, the provider may also be required to submit a provider-specific form (for example, an invoice) along with any MassHealth proprietary attachments. Please consult your provider manual for specific requirements.
For Long-Term Services and Supports (LTSS) providers, please refer to the LTSS provider portal for information about requesting LTSS PAs.
4. Once I submit a PA, how long does it take to adjudicate?
Standard requests: MassHealth will review and decide on standard prior authorization requests within 7 calendar days once all necessary documentation has been received. This includes all relevant member information, clinical attachments, and any additional notes required to meet prior authorization submission standards.
Expedited requests: MassHealth will review expedited prior authorization requests within 72 hours when the member’s clinical condition requires urgent attention and a delay in processing could negatively affect health outcomes. If the request does not meet the criteria for expedited review, it will be processed as a standard request and follow standard review processes, including the deferral process, as applicable.
For detailed submission requirements, please refer to the applicable provider manual.
5. What is MMIS?
Providers can easily access the Medicaid Management Information System (MMIS) through the Internet to submit prior authorization requests and attachments electronically, including photographs and X rays. MMIS will assign a tracking number to the PA submission. The tracking number is used for tracking purposes only, and consists of nine digits (the tracking number is not the prior authorization number, which consists of one letter followed by nine digits). While the tracking number is available to the provider immediately, the PA number will not be available until a decision on the PA request has been made.
6. What is the process once the PA request is received?
Providers may submit PAs either online or on paper. As outlined in MassHealth All Provider Bulletin 369, paper submissions are only accepted if you have an approved MassHealth claims waiver. We strongly encourage online submission. If submitted online, the system performs validation checks to ensure that required fields are completed and certain minimum information such as provider ID, member ID, procedure code, and dates are included and are valid. The PA is stamped with the receipt date. The PA is then forwarded to the appropriate consultant for review and decision. After a decision is made, decision letters are mailed to both the provider and the member.
7. Who reviews the PA request?
Consultants with education and experience in the service area review the PA form and supporting documentation. These clinical reviewers include physicians, nurses, and therapists. Requests for physical therapy services, for example, are reviewed by physical therapists.
8. What standard is used when a decision is made?
The standard is medical necessity. MassHealth will not pay a provider for services that are not medically necessary. A service is medically necessary if:
- it is reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the member that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a handicap, or result in illness or infirmity; and
- there is no other medical service or site of service, comparable in effect, available, and suitable for the member requesting the service, that is more conservative or less costly to MassHealth. Medically necessary services must be of a quality that meets professionally recognized standards of health care and must be substantiated by records including evidence of such medical necessity and quality.
9. What standard is used when a decision to expedite a PA is made?
MassHealth will review expedited prior authorization requests within 72 hours when the member’s clinical condition requires urgent attention and a delay in processing could negatively affect health outcomes.
Please note that changes to the date of a scheduled procedure, or the sudden availability of clinical services, do not qualify as an expedited prior authorization. Expedited review is only for urgent cases where a delay could cause serious harm. It is not for convenience, preference, or routine care.
10. What are the possible PA statuses?
The PA request may be assigned any of the following statuses.
- Submitted for Review - the request is submitted and awaiting review.
- Approve the request - the request is authorized.
- Deny the request - the request is denied and MassHealth will not reimburse for the service.
- Modify the request - the approval is for a service/product that is different in quantity or duration than that which was originally requested, but it was determined that the approved service or product is appropriate to meet the medical needs of the member.
- Defer the request - the request cannot be adjudicated as additional information is needed to make a decision; the provider is asked to submit supporting documentation.
11. Are there time limits that apply to decisions?
MassHealth is required to respond to appropriately completed and submitted requests for PA within the following time periods, in accordance with 130 CMR 450.303:
- Standard PA requests – within 7 calendar days from the date the PA is received
- Expedited PA requests – within 72 hours from the date and time the PA is received. If the PA does not meet the criteria for an expedited request, it will be responded to within 7 calendar days from the date the PA is received.
If a PA is deferred, the provider has 14 calendar days from the date of deferral to provide additional information. If the provider does not submit additional information to MassHealth within 14 calendar days after the deferral, the PA will be denied. Please refer to your specific program regulations for more information.
12. How is the consultant's decision communicated?
Once a decision is made, a notice is sent to the provider through the provider's preferred method of communication and a notice is mailed to the member. The notice advises both parties of the decision and the rationale for the decision. When a PA is submitted via the POSC or the LTSS Provider Portal, the decision can be viewed via the same application. In this way, the provider is aware of the decision in advance of receiving notification via post mail.
13. What is a PA request is deferred?
If a PA is deferred, notification is sent to both the provider and member, explaining the reason for the deferral; e.g. missing documentation. The provider may submit the additional information needed by attaching it electronically to the online PA request. Once the additional information is received by the PA unit, review and adjudication can continue. Providers have 14 calendar days to respond to a deferral.
For LTSS providers, please refer to the LTSS provider portal for information about deferred LTSS PAs.
14. What if a PA is modified or denied?
If a PA request is modified or denied, the member has a right to appeal if they disagree with the decision. Decision letters detailing the reason for the modification or denial are sent to the provider and the member and an explanation of the member's right to appeal and how to appeal are provided to the member.
15. Can members appeal PA decisions?
Yes. Whenever a PA request is approved, modified, or denied, a letter is sent to the member explaining the decision and providing the reason the decision was made. Also included in the letter is information explaining the member's appeal rights. MassHealth's Board of Hearings is the entity that hears appeals. If needed, interpreter services or assistive devices are available to members during the hearing. For questions about the appeals process, call the Prior Authorization Unit at (800) 862-8341 or the Board of Hearings at (617) 847-1200; for questions about assistive services available during the hearing, call the MassHealth Disability Ombudsman at (617) 847-3468.
16. Where can a provider check the status of a specific PA request?
Providers may access a previous PA request, and verify its status, by logging into their account on the Provider Online Service Center. The POSC will offer providers the most accurate summary of recent requests. For step-by-step guidance on how to navigate the POSC, providers can utilize POSC Job Aids available on Mass.gov.
For LTSS providers, please refer to the LTSS provider portal for information about how to check status of LTSS PAs.
17. How can I get a provider manual or copies of forms?
Providers may access forms in the MassHealth Provider Library in both a PDF and Word document format. Provider Manuals are also available on Mass.gov, and listed alphabetically according to provider type.
Glossary of PA Terms
MMIS Terminology
Adjudicated - MassHealth has made a decision on the PA.
Approved - authorization to perform/provide services/product is granted as requested.
Attachment - documentation accompanying the PA request, which establishes the reason that the service requested is medically necessary. Attachments may include, but are not limited to: a letter of medical necessity, a prescription, an invoice, a growth chart, etc. Specific required attachments are determined by the service being requested.
Consultant - a clinical professional educated and having experience in a specific clinical field, such as nursing, medicine, or physical therapy.
Deferred - adjudication of the PA request is halted due to lack of sufficient documentation to render a decision. Adjudication continues once the provider submits the additional documentation. In the event that the provider fails to submit the required additional documentation within the required timeframe, the PA request is denied.
Denied - the request is denied and MassHealth will not reimburse for the service.
Medical necessity - A service is medically necessary if
- It is reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the member that endanger life, cause suffering or pain, cause physical deformity or malfunctions, threaten to cause or to aggravate a handicap, or result in illness or infirmity, and
- There is no other medical service or site of service, comparable in effect, available, and suitable for the member requesting the service, that is more conservative or less costly to MassHealth. Services that are less costly MassHealth include, but are not limited to, health care reasonably known by the provider, or identified by MassHealth pursuant to a prior-authorization request, to be available to the member through sources described in 130 CMR 450.317(C), 503.007, or 517.007. Medically necessary services must be of a quality that meets professionally recognized standards of health care and must be substantiated by records including evidence of such medical necessity and quality.
Modified - the approval is for a service/product that is different in quantity or duration than that which was originally requested, but it was determined that the approved service or product is appropriate to meet the medical needs of the member.
MMIS PA number - the number assigned by MMIS to a PA after review and final adjudication is made. The PA number is 10 characters long, and is constructed as follows.
PYYJJJNNNN
P = Prior Authorization
YY = the Year
JJJ = Julian date
NNNN = four-digit sequence
Tracking Number - a nine-digit number assigned by MMIS to a PA request that has been keyed in the system. For PAs submitted via the POSC, the tracking number can be used by the provider to ascertain the status of the PA request while it is in process--that is, not yet adjudicated. Upon adjudication, the provider is notified of the decision and the Prior Authorization number is made available.
| Last updated: | December 24, 2025 |
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