Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.411 - Prior Authorization (PA) Requirements

Current through Register 1525, July 5, 2024
(A) Prior authorization must be obtained from
			 the MassHealth agency or its designee as a prerequisite for payment for CSN
			 agency services and before services are provided to the member. Without such
			 prior authorization, CSN agency services will not be paid by the MassHealth
			 agency.
(B) Prior authorization
			 determines only the medical necessity of the authorized service, and does not
			 establish or waive any other prerequisites for payment such as member
			 eligibility or resort to health-insurance payment.
(C) The MassHealth agency or its designee
			 will conduct the assessment of need for CSN agency services, including CSN
			 services and complex care assistant services, and coordinate other MassHealth
			 LTSS for the member, as appropriate. When the MassHealth agency or its designee
			 conducts an assessment of need for CSN agency services and authorizes CSN
			 agency services for the member, the member will select the CSN agency or
			 agencies that will be responsible for providing CSN agency services. The
			 MassHealth agency or its designee will provide written notification of its
			 assessment to the member, and if applicable, the CSN agency or agencies
			 selected by the member.
(D) At the
			 request of the MassHealth agency or its designee, CSN agencies are required to
			 provide a signed plan of care under
			 130
			 CMR 438.416 and supporting clinical
			 documentation including, but not limited to, nursing progress notes, complex
			 care assistant progress notes, medication records, and clinical logs to the
			 MassHealth agency or its designee for all members authorized for CSN agency
			 services.
(E) The MassHealth agency
			 or its designee will specify on the prior authorization for CSN agency services
			 the number of CSN hours and complex care assistant hours, as applicable, that
			 have been determined to be medically necessary and that are authorized for the
			 provider to provide to the member per calendar week and the duration of the
			 prior authorization. Any CSN hours or complex care assistant hours provided to
			 the member by a CSN agency that exceed what the MassHealth agency or its
			 designee has authorized in a calendar week are not payable by MassHealth,
			 except as described at
			 130
			 CMR 438.411(F).
(F) If there are unused hours of CSN services
			 in a calendar week, they may be used at any time during the current authorized
			 period.
(G) MassHealth members
			 and/or primary caregivers will determine when authorized CSN hours and complex
			 care assistant hours will be used in order to best support the member's needs.
			 This can include scheduling authorized service hours in increments of less than
			 two hours in order to meet the member's needs and best utilize authorized
			 hours.
(H) If the frequency of the
			 member's CSN agency services needs to be adjusted because
(1) the member's medical needs have changed
			 from current authorization, the CSN agency must contact the MassHealth agency
			 or its designee to request an adjustment to the prior authorization;
(2) there is a change in other nursing and
			 health care services or care from current authorization (for example: PCA
			 services, changes in Adult Day Health or Day Habilitation schedules, Adult
			 Foster Care services), the CSN agency or the member may contact the MassHealth
			 agency or its designee to request a review of the prior
			 authorization.