130 CMR, § 434.409 - Prior Authorization

(A) For certain outpatient services described in 130 CMR 434.000, the MassHealth agency requires that the psychiatric inpatient hospital obtain prior authorization. No payment will be made for such services unless prior authorization has been obtained from the MassHealth agency. Members participating in a MassHealth managed care plan require service authorization before certain mental health and substance abuse services are provided. For more information, see 130 CMR 450.124.

(B) 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 or resort to health insurance payment.

(C) All requests for prior authorization must be submitted in accordance with the instructions in Subchapter 5 of the Psychiatric Hospital Outpatient Services Manual.

(D) Time requirements for response from the MassHealth agency and rules that apply in determining the period within which the MassHealth agency will act on specific requests for prior authorization are set forth in the MassHealth administrative and billing regulations in 130 CMR 450.000. A service is authorized on the date the MassHealth agency transmits its decision concerning the request for prior authorization to the provider.

(E) Written notification of the prior authorization decision will be sent to the provider and will indicate approval, deferral because additional information is necessary, modification, or denial. In the case of a denial, the member will also be notified. Notification of denial will include the reason for the decision. The member or the provider has the right to resubmit a request and furnish additional information. The member may appeal the modification or denial of a prior authorization request within 30 days after the date of the notice of denial. Procedures for such an appeal are set forth in 130 CMR 610.000.

Notes

130 CMR, § 434.409