Guidelines for Medical Necessity Determination

UMass Medical School’s Center for Health Policy and Research, working with MassHealth, the state Medicaid program, develops clinical guidelines for medical services and products that require prior authorization such as organ transplants, cranial orthoses, and other high-risk, high-cost, and/or high volume services.

The guidelines and their associated forms are intended to be a checklist of the specific medical information that MassHealth needs to determine medical necessity.  The guidelines are published online at the MassHealth website.

Clinical guidelines are developed by reviewing the latest medical literature and conducting environmental scans of the policies and practices of other Medicaid programs, public and private health plans, and health-related trade and professional organizations.  All guidelines undergo rigorous peer review by medical experts before they are implemented.  The guidelines are reviewed and updated as state and federal Medicaid policies change.