130 CMR 408.507 - GAFC Clinical Assessment and Prior Authorization
(A)
Clinical
Assessment. As part of the prior authorization process, members
seeking GAFC must undergo a clinical assessment to assess the member's clinical
status and need for GAFC. Completed clinical assessment documentation must be
submitted to the MassHealth agency, or its designee, in the form and format
requested by the MassHealth agency. A new clinical assessment is required
annually and upon significant change. The MassHealth agency reserves the right
to conduct the clinical assessment.
(B)
Prior
Authorization.
(1) as a
prerequisite for payment of GAFC, the GAFC provider must obtain prior
authorization from the MassHealth agency or its designee before the first date
of service delivery and annually thereafter, and upon significant
change.
(2) prior authorization
determines the medical necessity for GAFC as described under 130 CMR 408.507
and in accordance with
130 CMR
450.204: Medical
Necessity.
(3) prior
authorization may specify the service amount for payment for the
service.
(4) prior authorization
does not establish or waive any other prerequisites for payment such as the
member's financial eligibility described in
130 CMR
503.007: Potential Sources of Health
Care and
130 CMR
517.008: Potential Sources of Health
Care.
(5) when submitting
a request for prior authorization for payment of GAFC to the MassHealth agency,
or its designee, the GAFC provider must submit requests in the form and format
required by the MassHealth agency. The GAFC provider must include all required
information including, but not limited to, documentation of the completed
clinical assessment conducted by the MassHealth agency or its designee; other
nursing, medical or psychosocial evaluations or assessments; and any other
documentation that the MassHealth agency, or its designee, requests in order to
complete the review and determination of prior authorization.
(6) in making its prior authorization
determination, the MassHealth agency or its designee, may require additional
assessments of the member or require other necessary information in support of
the request for prior authorization.
(C)
Notice of Determination of
Prior Authorization.
(1)
Notice of Approval. If the MassHealth agency or its
designee approves a request for prior authorization, it will send written
notice to the member and the GAFC provider.
(2)
Notice of Denial or Service
Modification. If the MassHealth agency or its designee denies, or
approves with a service modification, a request for prior authorization of
GAFC, the MassHealth agency or its designee will notify both the member and the
GAFC provider. The notice will state the reason for the denial or service
modification and contain information about the member's right to appeal and the
appeal procedure.
(3)
Right of Appeal. A member may appeal a service denial
or modification by requesting a fair hearing in accordance with
130 CMR 610.000:
MassHealth Fair Hearing Rules.
(D)
Review
Requirement. The MassHealth agency, or its designee, may at any
time, review prior authorization of MassHealth members including, but not
limited to, instances in which there has been a significant change in the
member's status as defined in 130 CMR 408.502.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.