New MassHealth Rules on New Prior Authorization Process

In response to concerns about growth in home health utilization over the past two years, MassHealth has used their emergency regulation authority to introduce a home health prior authorization requirement as of March 1. According to MassHealth staff, the visit count for determining the need for prior authorization will start on March 1. Prior authorization is required for services in excess of the following thresholds:

  • Intermittent skilled nursing visits after 30 visits in a 90-day period;
  • Home health aide services after 240 units (60 hours) in a 90-day period;
  • Physical therapy after 20 visits in a 12-month period (this is unchanged from previous requirement;
  • Occupational therapy after 20 visits in a 12-month period;
  • Speech-language therapy after 35 visits in a 12-month period;
  • Home Health Aide services supportive of physical, occupational, or speech-language therapy after 20 physical, 20 occupational, or 35 speech-language therapy visits.

MassHealth has published numerous instructional documents, the links of which can be found below .  Links to the PA request forms and guidelines are also within the bulletin.

Bulletin:

http://www.mass.gov/eohhs/gov/laws-regs/masshealth/provider-library/provider-bulletins/home-health-agency-provider-bulletins.html

Transmittal Letter

http://www.mass.gov/eohhs/gov/laws-regs/masshealth/provider-library/transmittal-letters/home-health-agency-transmittal-letters.html

Home Health Medical Necessity Guideline:

http://www.mass.gov/eohhs/provider/insurance/masshealth/clinical-treatment/medical-necessity-determination/download-a-printer-friendly-version-of-the.html

HHA-2 and PA-HHA-SN forms (will be under Home Health Agency):

http://www.mass.gov/eohhs/gov/laws-regs/masshealth/provider-library/masshealth-provider-forms.html

It is expected that PAs will be processed through the MassHealth Provider Online Service Center (POSC).  All of the job aides and training links related to this can be found here:

http://www.mass.gov/eohhs/gov/newsroom/masshealth/providers/mmis-posc/trainingget-trained.html

HCA of MA continues to work with MassHealth to clarify agency questions and concerns around documentation and PA processing.  A list of Q & As should be available shortly.

 

 

 

 

 

 

 

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