Section 450.303 - Prior AuthorizationIn certain instances, the MassHealth agency requires providers to obtain prior authorization to provide medical services. These instances are identified in the billing instructions, program regulations, associated lists of service codes and service descriptions, provider bulletins, and other written issuances from the MassHealth agency. Such information including, but not limited to, the MassHealth Drug List is available on the MassHealth website at www.mass.gov/druglist , and copies may be obtained upon request. The provider must submit all prior-authorization requests in accordance with the MassHealth agency instructions. 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.
(A) The MassHealth agency acts on appropriately completed and submitted requests for prior authorization within the following time periods. (1) For pharmacy services - by telephone or other telecommunication device within 24 hours of the request for prior authorization. The MassHealth agency will authorize at least a 72-hour supply of a prescription drug to the extent required by federal law. (See42 U.S.C. 1396r-8(d)(5).)(2) For transportation to medical services - within seven calendar days after a request for service, or the number of days, if less than seven, necessary to avoid any serious and imminent risk to the health or safety of the member that might arise if the MassHealth agency did not act before the full seven days have elapsed.(3) For independent nurse services - within 14 calendar days after a request for service.(4) For durable medical equipment - within 15 calendar days after a request for service.(5) For all other MassHealth services - within 21 calendar days after a request for service.(B) The following rules apply for prior-authorization requests.(1) The date of any prior-authorization request is the date the request is received by the MassHealth agency, if the request conforms to all applicable submission requirements including, but not limited to, the form, the address to which the request is sent, and required documentation.(2) If a provider submits a request that does not comply with all submission requirements, the MassHealth agency informs the provider(a) of the relevant requirements, including any applicable program regulations;(b) that the MassHealth agency will act on the request within the time limits specified in 130 CMR 450.303 if the required information is received by the MassHealth agency within four calendar days after the request; and(c) that if the required information is not submitted within four calendar days, the MassHealth agency's decision may be delayed by the time elapsing between the four days and when the MassHealth agency receives the necessary information.(3) A service is authorized on the date the MassHealth agency sends a notice of its decision to the member or someone acting on the member's behalf.(C) The MassHealth agency does not act on requests for prior authorization for (1) covered services that do not require prior authorization; or(2) noncovered services, except to the extent that MassHealth regulations specifically allow for prior-authorization requests.Amended by Mass Register Issue 1341, eff. 6/16/2017.Amended by Mass Register Issue 1373, eff. 6/16/2017.Amended by Mass Register Issue 1374, eff. 10/1/2018.