Section 456.407 - Clinical Authorization of Nursing Facility Services(A) Clinical authorization for nursing facility services may be for a specified or indefinite length of stay. Authorizations for an indefinite length of stay may be subject to review by the MassHealth agency or its agent to ensure that conditions for payment continue to be met. A clinical authorization is required (1) before the first date of service delivery for which the nursing facility is seeking payment from MassHealth;(2) when a member is transferred from one nursing facility to another nursing facility;(3) when a member who is hospitalized is to be admitted to a different nursing facility from the one the member resided in before the hospital admission;(4) when a member who has been hospitalized for over six months seeks to be readmitted to the nursing facility where the member resided before hospital admission; and(5) when a nursing facility determines that a member has discharge potential, or the member may no longer meet the clinical eligibility criteria described in 130 CMR 456.409.(B) The MassHealth agency notifies nursing facilities, hospitals, physicians or PCPs, and home health agencies of the identity of the agent responsible for authorizing nursing facility services.(C) The referring medical provider must submit the request for authorization of nursing facility services to the MassHealth agency or its agent on behalf of the member. For persons who become eligible for MassHealth while residing in a nursing facility, the facility itself must submit the request for authorization. The request for authorization of nursing facility services must be submitted on the forms required by the MassHealth agency and must include documentation that available alternatives to institutionalization were considered and were deemed inadequate to meet the member's needs.(D) If the MassHealth agency determines that a member is eligible for nursing facility services, the MassHealth agency will issue a notice that contains the effective date of coverage.(E) As a prerequisite for payment, nursing facilities must obtain clinical authorization from the MassHealth agency or its designee for each member or MassHealth applicant for whom the nursing facility provider is seeking MassHealth payment.(F) Clinical authorization determines the medical necessity of nursing facility services as described in 130 CMR 456.409, in accordance with 130 CMR 450.204: Medical Necessity. Approval does not establish or waive any other prerequisites for payment, such as the member's financial eligibility for MassHealth.(G) As part of the clinical authorization process, MassHealth or its designee must assess the member or MassHealth applicant's need for nursing facility services.(H) Requests for authorization for nursing facility services must be submitted to MassHealth, or its designee, in the form and format specified by MassHealth or its designee. (1) A complete authorization request must include all required information, including, but not limited to, documentation of the completed clinical assessment; other nursing, medical, or psychosocial evaluations or assessments; documentation that available alternatives to institutionalization were considered and were deemed inadequate to meet the member's needs; and any other documentation that the MassHealth agency, or its designee, requests in order to complete the review and determination of clinical authorization, including additional assessments of the member.(2) In making its clinical authorization determination, MassHealth or its designee may require additional assessments of the member or require other necessary information in support of the request for clinical authorization.Amended by Mass Register Issue 1505, eff. 10/1/2023.