Referrals
Referrals are required for certain specialty services in both the Primary Care Clinician Plan and primary care accountable care organizations [under MassHealth regulations 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 member’s coverage type. For specific instructions on how to submit, update, or ask about a referral, please see the MassHealth Provider Online Service Center (POSC) job aids.
Dental providers should refer to the MassHealth Dental Program website for more information.
Prior Authorization
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, lists of service codes and service descriptions, provider bulletins, MassHealth Drug List, and other documents from MassHealth. Relevant documents, including the MassHealth Drug List, are available on the Prior Authorization for MassHealth Providers web page, and providers can get copies on request. The provider must submit all PA requests in accordance with MassHealth’s instructions. PA 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. See 130 CMR 450.303.
There are two types of PA requests: PA for a drug or PA for nonpharmacy services.
Certain dental providers may use the POSC for a prior authorization related to CPT codes and may contact the MassHealth Dental Program for more information regarding these differences.
LTSS providers can learn more at the LTSS provider portal.
Pharmacy Authorization
Providers should use the MassHealth Prior Authorization Forms for Pharmacy Services when a drug or non-drug product requires PA under the MassHealth Drug List. You can find information on how to request PA for a drug, as well as other related forms, at our web page on drug PA requests.
PA for Durable Medical Equipment and Oxygen/Respiratory Equipment
You can find PA requirements for durable medical equipment and oxygen/respiratory equipment in our MassHealth Durable Medical Equipment and Oxygen Payment and Coverage Guideline Tool.
PA for Orthotics and Prosthetics
You can find PA requirements for orthotics and prosthetics in the MassHealth Payment and Coverage Guideline Tool.
View the MassHealth Guidelines for Medical Necessity Determination here.
All non-LTSS providers submit PA requests through the POSC. Please view the corresponding job aid.
All LTSS providers submit PA requests through the LTSS provider portal. Please view the PA training and resources under Provider Resources in the portal.
Preadmission Screening, Prepayment Reviews, and Post-Payment Reviews
MassHealth conducts utilization management processes, including preadmission screening (PAS) for elective hospital admissions, prepayment reviews for medical necessity and compliance with other regulatory and billing requirements, and post-payment reviews.
MassHealth requires PAS for acute inpatient and chronic disease and rehabilitation hospitals. 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 ask about a PAS, please review our POSC job aids.
MassHealth also conducts reviews after discharge from inpatient settings but before payment (prepayment review).
Finally, MassHealth conducts post-payment utilization reviews of inpatient admissions and outpatient services and may pursue overpayment collection based on findings in accordance with 130 CMR 450.237.
Non-Emergency Medical Transportation
MassHealth provides non-emergency medical transportation for eligible members. For non-emergency sedan and wheelchair van transportation, providers must submit transportation requests using the PT-1 Form online via the MassHealth Customer Web Portal. See MassHealth Transportation Information for Providers for current instructions.
| Date published: | July 29, 2022 |
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| Last updated: | August 21, 2026 |