Section 428.412 - Prior Authorization(A) Services that require prior authorization as a prerequisite for payment are identified in 130 CMR 428.000 or are listed in Subchapter 6 of the Prosthetics Manual with the designation (P.A.) appearing after the service description. To determine if prior authorization is required, the provider should review both 130 CMR 428.000 and Subchapter 6. Prior authorization determines only the medical necessity of the prescribed item or service and does not waive any other prerequisites to payment such as member eligibility or resort to health-insurance payment.(B) The provider must request prior authorization in accordance with the billing instructions in Subchapter 5 of the Prosthetics Manual. Before determining the medical necessity of an item or service for which prior authorization is requested, the MassHealth agency may, at its discretion, require the prescriber to submit an assessment of the member's condition and the objectives of the requested service. The MassHealth agency may also, at its discretion, require an evaluation by a licensed prosthetist to determine whether the requested prosthetic service is useful to the member, given the member's physical condition and physical environment.(C)(1) The MassHealth agency will send notification to the member and the provider of the following prior-authorization decisions:(2) If the MassHealth agency defers the prior-authorization decision because additional information is required to determine whether the requested service is medically necessary, the MassHealth agency will notify the provider.(3) If the MassHealth agency denies or modifies a request, the notification will include the reason for the MassHealth agency's determination. The member may appeal the modification or denial of a prior-authorization request within 30 days after the date of the notice. Procedures for such an appeal are set forth in 130 CMR 610.000: MassHealth: Fair Hearing Rules.(D) The MassHealth agency will make a decision on the request within 15 days after the date of receipt of a fully completed prior-authorization request. The MassHealth agency will confirm the date of receipt and the date of action upon written request.(E) The provider must keep the prior-authorization request on file for the period of time required by 130 CMR 450.205: Recordkeeping and Disclosure.Amended by Mass Register Issue 1354, eff. 12/15/2017.Amended by Mass Register Issue 1494, eff. 4/28/2023.