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Getting services approved: Prior Authorization

There are some services and medicines that MassHealth has to approve before you get them.

The process of getting approval in advance is called Prior Authorization (PA).

If you need a service or drug that requires Prior Authorization (PA):

  • MassHealth must first confirm that it is medically necessary

  • This can take 1-10 days

  • It will go faster if MassHealth has your Disability Supplement

Prior Authorization will go faster if you file a disability supplement and provide diagnosis information.

A couple key notes:

  • Your doctor should get the PA from MassHealth. You don’t have to do it yourself. Your doctor will tell you if your request was approved or denied, and MassHealth will send you a letter as well.

  • If you are on the PCC plan, see pages 13-17 of the PCC Member Handbook to see which services need PA. Click the link at the bottom of the page to download a PDF of the handbook.

If you feel that your family member needs a service and MassHealth does not approve the PA for it, you can appeal. Click the box below for more information about the appeals process.

There may be times when MassHealth denies coverage for a prescription drug or a service that your family member needs.

If this happens, you have the right to appeal their decision.

Here's what you can do:

  1. Click the link at the bottom of the page to download a PDF of the Health Law Advocates' Guide to Appeals

  2. On page 19, you will find a sample letter that you can send to your insurance company to ask for an appeal

  3. Get help from your doctor. They can contact MassHealth and explain why your family member needs the service or prescription drug

Source: MassHealth

 

There are three steps to the MassHealth appeals process. One: Request a fair hearing. This is a formal session in court where you can explain why you disagree with the denial. Fill out the request form (download below) and send it in within 30 days of getting the denial letter. Two: Prepare for your hearing. Read your rights on the Fair Hearing Request Form. Gather any documents that show why your family member should qualify. These could be reports from doctors, therapists or others. Ask for help if ther's anything you don't understand. (See list below). Three: Attend the hearing and explain why you disagree with the decision. Get there on time, and contact the Board of Hearings at 617-847-1200 if you are running late or need to reschedule. Bring your family member with you if they are over the age of 18 and you do not have Power of Attorney, Guardianship, or Authorized Representative status.

To request a fair hearing, click the link at the bottom of the page to download a PDF of the form.

If your family member is over 18 and you have Power of Attorney or Guardianship, you must include a copy of those documents AND the MassHealth Authorized Representative Designation form.

 

Click the link for the MassHealth Authorized Representative Designation Form to download a PDF of the form.

 

After you fill out the form, you can mail it to:

Board of Hearings

Office of Medicaid

100 Hancock Street, 6th Floor

Quincy, MA 02171

 

If you do not request a hearing within 30 days after you receive the denial letter, there is a different process you must go through.

 

Click the Letter Template link at the bottom of the page to download a PDF of the form.

 

Here's who to call to get help with the appeals process: Health Care for All, 1-800-272-4232, Health Law Advocates, 617-338-5241, Autism Insurance Resource Center, 1-774-455-4056, MassHealth, 1-800-841-2900.

Sources: Health Care for All, Health Law Advocates,MassHealth

Denial of coverage

There may be times when MassHealth denies coverage for a prescription drug or a service that your family member needs.

If this happens, you have the right to appeal their decision.

To learn how, click the box below:

If you ever think that your family member is having a life-threatening or urgent emergency, do not wait. Call 911 or go to the hospital right away! Once the emergency has been handled, then you can find out which services are covered (paid for) by your family member's insurance.

Sources: MassHealth, Patient Advocate Foundation