130 CMR 420.410 - Prior Authorization

(A) Introduction.

(1) The MassHealth agency pays only for medically necessary services to eligible MassHealth members and may require that medical necessity be established through the prior authorization process. In some instances, prior authorization is required for members 21 years of age or older when it is not required for members younger than 21 years old.

(2) Services requiring prior authorization are identified in Subchapter 6 of the Dental Manual, and may also be identified in billing instructions, program regulations, associated lists of service codes and service descriptions, provider bulletins, and other written issuances. The MassHealth agency only reviews requests for prior authorization where prior authorization is required or permitted (see130 CMR 420.410(B)) .

(3) The provider must not start a service that requires prior authorization until the provider has requested and received written prior authorization from the MassHealth agency. The MassHealth agency may grant prior authorization after a procedure has begun if, in the judgment of the MassHealth agency

(a) the treatment was medically necessary;

(b) the provider discovers the need for additional services while the member is in the office and undergoing a procedure; and

(c) it would not be clinically appropriate to delay the provision of the service.

(B) Services Requiring Prior Authorization. The MassHealth agency requires prior authorization for:

(1) those services listed in Subchapter 6 of the Dental Manual with the abbreviation "PA" or otherwise identified in billing instructions, program regulations, associated lists of service codes and service descriptions, provider bulletins, and other written issuances;

(2) any service not listed in Subchapter 6 for an EPSDT-eligible member; and

(3) any exception to a limitation on a service otherwise covered for that member as described in 130 CMR 420.421 through 420.456. (For example, MassHealth limits prophylaxis to two per member per calendar year, but pays for additional prophylaxis for a member within a calendar year if medically necessary.)

(C) Submission Requirements.

(1) The provider is responsible for including with the request for prior authorization appropriate and sufficient documentation to justify the medical necessity for the service. Refer to Subchapter 6 of the Dental Manual for prior-authorization requirements.

(2) Instructions for submitting a request for prior authorization for Current Dental Terminology (CDT) codes are described in the MassHealth Dental Program Office Reference Manual. Dental providers requesting prior authorization for services listed with a CDT code must use the current American Dental Association (ADA) claim form.

(3) Instructions for submitting a request for prior authorization for CPT codes are described in the administrative and billing instructions (Subchapter 5) in all provider manuals. The provider must submit prior authorization requests for CPT codes to MassHealth in accordance with the instructions in Appendix A of all provider manuals.

(D) Other Requirements for Payment.

(1) 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, the availability of other health-insurance payment, or whether the service is a covered service.

(2) The MassHealth agency does not pay for a prior-authorized service when the member's MassHealth eligibility is terminated on or before the date of service.

(3) When the member's MassHealth eligibility is terminated before delivery of a special-order good, such as denture(s) and crown(s), the provider may claim payment in accordance with the provisions of 130 CMR 450.231(B): General Conditions of Payment. Refer to 130 CMR 450.231(B) for special procedures in documenting member eligibility for special-order goods.

Notes

130 CMR 420.410

Amended by Mass Register Issue 1342, eff. 6/30/2017. Amended by Mass Register Issue 1344, eff. 7/1/2017. Amended by Mass Register Issue 1454, eff. 10/15/2021.