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Q 1: I have heard that MassHealth has increased the number of visits for physical therapy (PT), occupational therapy (OT), and speech/language therapy (ST) that MassHealth pays for without prior authorization. Is this true?
A 1: Yes. Effective for dates of service on or after January 1, 2005, after 20 PT visits, 20 OT visits, or 35 ST visits, within a rolling 12-month period, you will need to request prior authorization from MassHealth for additional therapy visits of that type during that 12-month period.
Please note that the MassHealth managed care organizations (MCOs) (Boston Medical Center HealthNet Plan, Fallon Community Health Plan, Network Health, and Neighborhood Health Plan), Senior Care Options (SCO), and Program of All-inclusive Care for the Elderly (PACE) may have prior-authorization policies that differ from the MassHealth policy described above. MassHealth members enrolled in these MCOs are subject to the prior-authorization policies of their health plan.
Q 2: Is MassHealth planning to revise its regulations to reflect these changes?
A 2: Yes. MassHealth will update its regulations in the coming months to reflect these changes. See the following MassHealth bulletins, below, for more information about these changes.
Q 3: Does the 12-month period mean a calendar year or will it be tracked on a rolling basis?
A 3: For members not currently receiving therapy services under a prior authorization the 12-month period begins on the date of the first therapy visit after January 1, 2005, and ends 12 months later. This is considered a "rolling 12-month period." For members who are receiving therapy services under a prior authorization, the rolling calendar year begins on the first therapy visit after the prior authorization expires or has been exhausted, and ends 12 months later. (For example, for a member receiving therapy under a prior authorization that expires on March 15, 2005, the rolling 12-month period begins on the date of the first therapy visit after March 15, 2005, and ends 12 months later.
Q 4: Does the initial evaluation by the therapist count as one of the visits?
A 4: No. Effective for dates of service on or after January 1, 2005, for providers who can bill separately, comprehensive evaluations and reevaluations do not require prior authorization and do not count toward a visit.
Q 5: Can I fax a prior-authorization request for PT, OT, or ST?
A 5: No.
Q 6: What is the maximum date range or maximum number of visits a provider can request on a prior authorization?
A 6: There is no maximum date range or number of visits. The number of visits and the duration approved is based on what is deemed medically necessary, based on documentation submitted with the prior-authorization requests. Suitable documentation should support the medical necessity of the duration of requested visits (for example, plan of care, goal, services plan, or any other evidence of medical necessity). The Request and Justification Form for Therapy Services (R&J) can be used to provide this documentation.
Q 7. When should I send the request for prior authorization to MassHealth for a member who will exceed 20 physical therapy visits, 20 occupational therapy visits, or 35 speech therapy visits?
A 7: Providers should request prior authorization as soon as it is evident that more therapy visits are medically necessary. Prior authorization is a prerequisite to payment. If MassHealth determines that the requested care is medically necessary, MassHealth will pay for the approved therapy services in excess of these thresholds as long as the PA request date is before the actual start date of the service.
Q 8: Must the evaluation be included with the prior-authorization request?
A 8: Yes. As stated in the R&J form, for first requests, you must attach a copy of your initial evaluation. For subsequent requests, you must also attach a copy of the last two evaluations.
Q 9: Is the R&J form always required with a prior-authorization request?
A9: Yes. Providers must always attach a completed R&J form to the completed prior-authorization request for therapy services.
Q 10: Should a provider request prior authorization in terms of units or visits?
A 10: Both. Providers must specify the number of units when using the Provider Online Service Center (POSC). Providers must specify the number of visits requested on the R&J form, which must accompany the request.
Q 11: Is authorization for services given in units or visits?
A 11: Authorization for PT, OT, and ST is given in units. The MassHealth reviewer also notes the number of visits that the reviewer believes is needed to use the units.
Q 12: What is needed and who is responsible for requesting Prior Authorization either through the Provider Online Service Center or on paper?
A 12: Unless otherwise specified in MassHealth program regulations, if the therapist is requesting prior authorization, the request must include the doctor's orders. If the physician is providing the therapy, however, the physician must request prior authorization. If a physician employs a therapist and the therapist does not have a MassHealth provider number, the physician requests the prior authorization. If organized as a group practice, providers must use their servicing provider number, rather than their group practice provider number, when requesting prior authorization.
Q 13: MassHealth reviews request for prior authorization on the basis of medical necessity only. If MassHealth approves the request, payment is still subject to all general conditions of MassHealth, including current member eligibility, other insurance, and program restrictions. MassHealth will notify the provider and member of its decision.
A 13: Prior authorization is for medical necessity only. There are many reasons why MassHealth will not pay a claim even if a request for prior authorization is approved for the service. For example, MassHealth does not pay a claim if the member is not eligible for MassHealth on the date of service or if the claim is completed incorrectly.
Q 14: Do I need to get a referral from the member's PCC before providing therapy services?
A14: If a member is enrolled in the MassHealth Primary Care Clinician (PCC) Plan, you need a referral from the member's PCC before MassHealth will pay for any therapy services. The referral number must be placed on the claim form or electronic equivalent.
If the member is enrolled in one of the MassHealth-contracted MCOs, SCOs, or PACE, the member is subject to the referral policies of that health plan.