Form PA-1 "Prior Authorization Request" - Massachusetts

What Is Form PA-1?

This is a legal form that was released by the Massachusetts MassHealth - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2017;
  • The latest edition provided by the Massachusetts MassHealth;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form PA-1 by clicking the link below or browse more documents and templates provided by the Massachusetts Masshealth.

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Download Form PA-1 "Prior Authorization Request" - Massachusetts

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Prior Authorization Request
MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth approves the
request, payment is still subject to all general conditions of MassHealth, including current member eligibility, other insurance,
Commonwealth of Massachusetts • EOHHS
and program restrictions. MassHealth will notify the provider and member of its decision. Providers must complete items 1-22
www.mass.gov/masshealth
or risk delays, as described at 130 CMR 450.303(B).
1. Provider’s Name, Address, and Tel.
4. Member’s Name, Address, and Tel. No.
Contact Name
5. Place of Residence:
Home
Nursing facility
Rehab. hospital
Other: _____________________________________________
Contact Tel. No.
6. Height _______ ft. _______ in. 7. Weight _______ lb. _______ oz.
Contact Fax
8. Gender
M
F 9. Other Insurance
Yes
No
2. Provider ID/Service Location or NPI
10. Full Name of Insurance Carrier
3. PA Assignment
11. Date of Birth
12. Member ID
/
/
13. Community Case Management Member Identifier
Yes
No
SERVICES REQUESTED
14.
15.
16.
17.
Explain why this service is medically necessary. Include the diagnosis,
Servicing Provider ID/Service
Service Code (Use a separate line
No. of Units
place of service, and a description of the proposed treatment. Attach
Location or NPI
for each code.) Include modifier if
(Enter at least 1.)
supporting documentation if required by MassHealth regulations.
code requires one.
Primary Diagnosis
A
Secondary Diagnosis
B
Diagnosis Code(s)
Place of Service
C
Description of Treatment
D
E
18.
19.
20.
21.
Date PA Requested
Requested Effective Date
Requested End Date
Attachments
/
/
/
/
/
/
Yes
No
22. Provider Signature
I certify under the pains and penalties of perjury that the information on this form and any attached statement that I have provided has been reviewed and signed by me, and is
true, accurate, and complete, to the best of my knowledge. I also certify that I am the provider or, in the case of a legal entity, duly authorized to act on behalf of the provider. I
understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.
Provider’s signature
(Signature and date stamps, or the signature of anyone other than the provider or a person legally authorized to sign on behalf of a legal entity, are not acceptable.)
Printed legal name of provider
Printed legal name of individual signing (if the provider is a legal entity)
PA-1 (Rev. 06/17)
Prior Authorization Request
MassHealth reviews requests for prior authorization (PA) on the basis of medical necessity only. If MassHealth approves the
request, payment is still subject to all general conditions of MassHealth, including current member eligibility, other insurance,
Commonwealth of Massachusetts • EOHHS
and program restrictions. MassHealth will notify the provider and member of its decision. Providers must complete items 1-22
www.mass.gov/masshealth
or risk delays, as described at 130 CMR 450.303(B).
1. Provider’s Name, Address, and Tel.
4. Member’s Name, Address, and Tel. No.
Contact Name
5. Place of Residence:
Home
Nursing facility
Rehab. hospital
Other: _____________________________________________
Contact Tel. No.
6. Height _______ ft. _______ in. 7. Weight _______ lb. _______ oz.
Contact Fax
8. Gender
M
F 9. Other Insurance
Yes
No
2. Provider ID/Service Location or NPI
10. Full Name of Insurance Carrier
3. PA Assignment
11. Date of Birth
12. Member ID
/
/
13. Community Case Management Member Identifier
Yes
No
SERVICES REQUESTED
14.
15.
16.
17.
Explain why this service is medically necessary. Include the diagnosis,
Servicing Provider ID/Service
Service Code (Use a separate line
No. of Units
place of service, and a description of the proposed treatment. Attach
Location or NPI
for each code.) Include modifier if
(Enter at least 1.)
supporting documentation if required by MassHealth regulations.
code requires one.
Primary Diagnosis
A
Secondary Diagnosis
B
Diagnosis Code(s)
Place of Service
C
Description of Treatment
D
E
18.
19.
20.
21.
Date PA Requested
Requested Effective Date
Requested End Date
Attachments
/
/
/
/
/
/
Yes
No
22. Provider Signature
I certify under the pains and penalties of perjury that the information on this form and any attached statement that I have provided has been reviewed and signed by me, and is
true, accurate, and complete, to the best of my knowledge. I also certify that I am the provider or, in the case of a legal entity, duly authorized to act on behalf of the provider. I
understand that I may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.
Provider’s signature
(Signature and date stamps, or the signature of anyone other than the provider or a person legally authorized to sign on behalf of a legal entity, are not acceptable.)
Printed legal name of provider
Printed legal name of individual signing (if the provider is a legal entity)
PA-1 (Rev. 06/17)
INSTRUCTIONS FOR COMPLETING THE PA-1 FORM (PLEASE PRINT OR TYPE.)
General Instructions
Complete Items 1–22 only. Enter all dates in mm/dd/yyyy format. Below are instructions for specific fields. All other fields are self-explanatory.
Provider Information Section
Item 1
Provider’s Name, Address, and Tel. No. Enter the provider’s name, address, and phone number (including area code).
Item 2
Provider ID/Loc or NPI
Enter the nine-digit requesting-provider ID followed by the one-character location code.
If not available, enter the requesting provider’s 10-digit national provider identifier.
Item 3
PA Assignment
Select the type of PA you are requesting from this list of basic medical or long-term services and supports (LTSS) services:
Basic Medical
LTSS
Early Intervention
Home Health/Personal Care
Durable Medical Equipment
Therapy Services
Hearing Services
Attendant
AAC Non- Dedicated Device
Occupational Therapy
Physician-Adult
CarePlus Skilled Nursing
Absorbent Products
Physical Therapy
Physician-Pediatric
Home Health
DME–Other
Speech/Language Therapy
Vision
Personal Care Attendant (PCA) Services
Enterals
Wigs
Mobility and Repairs
Other
Orthotics and Prosthetics
Oxygen
PERS
Standers
Member Information Section
Item 4
Member’s Name, Address, and Tel. No. Enter the member’s name, address, and phone number (including area code).
Item 13
Community Case Management
Select the “Yes” box if the member for which the service is being requested is enrolled in the Community Case Management
Member Identifier
Program (CCM). CCM provides case management services to complex care members who require a nurse visit of more than
two continuous hours of nursing services to remain in the community, as determined by MassHealth or its designee. CCM
enrollment can be confirmed by checking the members’ eligibility on the MassHealth Eligibility Verification System (EVS), or
by checking the eligibility panel of the Provider Online Service Center (POSC). On the POSC left navigation, select Manage
Members, then Verify Member, then Eligibility.
Item 14
Explain why this service is medically
Enter a statement explaining why the proposed service is medically necessary. Include the primary diagnosis and secondary
necessary
diagnosis if there is one. Also include a description of the proposed treatment and prognosis. Refer to your MassHealth
provider manual for additional information about this field.
Diagnosis Code(s)
Enter the ICD diagnosis code(s) from ICD-10 for the most relevant diagnoses for the procedure or item being requested.
Place of Service
Enter the location of service.
Description of Treatment
Enter a narrative of the proposed treatment.
Services Requested Section
Item 15
Servicing Provider ID/Service
Enter the nine-digit servicing-provider ID followed by the one-character service location code. Write “same” if same as
Location or NPI
requesting provider ID/Service Location. If not available, enter the provider’s 10-digit national provider identifier.
Item 16
Service Code
Enter the appropriate CPT or HCPCS code for each service requested. Refer to Subchapter 6 of the applicable MassHealth
provider manual to determine payable service codes. You must include a modifier if the service code requires one.
Item 17
No. of Units
Enter the number of times that the service for which you are requesting PA will be furnished. At least “1” must be entered.
Attachments and Signature
Item 18
Attachments
Select the “Yes” box if additional information or supporting documentation is attached (refer to your provider manual);
otherwise select the “No” box. Be certain that the attached documentation clearly supports the medical necessity for the
services and/or equipment you are requesting (for example, X-rays, admission notes, photographs, or explicit details).
Item 22
Provider Signature
The form must be signed by the provider or, in the case of a legal entity, an individual duly authorized to act on
behalf of the provider to certify that the information entered on the form is correct. Signature and date stamps, or
the signature of anyone other than the provider or a person legally authorized to sign on behalf of a legal entity, are not
acceptable.
See Subchapter 5 of your MassHealth provider manual for additional instructions for requesting PA.
INSTRUCTIONS FOR MAILING REQUESTS FOR PRIOR AUTHORIZATION (See Item 3 above for Basic Medical or LTSS service options)
For PA requests for basic medical services, mail the Prior Authorization Request form,
For PA requests for LTSS services, mail the Prior Authorization Request form, together
together with all necessary attachments, to the following address:
with all necessary attachments, to the following address:
MassHealth
MassHealth LTSS
ATTN: Prior Authorization
P.O. Box 159108
100 Hancock Street, 6th Floor
Boston, MA 02215
Quincy, MA 02171
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