The MassHealth prior authorization program, managed by UMass Medical School’s Center for Health Policy and Research, provides a review process for a selection of non-routine medical services and procedures. Each case is examined on an individual basis by appropriate clinicians to determine whether the course of treatment is necessary, appropriate, and effective.
Medical services that require prior authorization include, but are not limited to:
- Durable medical equipment
- Oxygen and respiratory services
- Private duty nurses
- Personal care attendants
- Physical therapy
- Speech therapy
- Occupational therapy
- Vision care
In a typical month, UMass Medical School’s Center for Health Policy and Research reviews more than 10,000 requests. On average, 70 percent are approved; 10 percent are denied; and the remaining 20 percent of the services are approved with some modifications.
The prior authorization program is also responsible for coordinating care for medically complex cases, such as long-term rehabilitation or even organ transplants. Each case is assigned a team that includes a nurse practitioner and three licensed social workers. Using a model that considers a patient’s medical, physical, psychological, and social needs, the team recommends and coordinates the following:
- Placement for patients with difficult or chronic conditions who do not belong in an acute treatment setting, such as hospitals,
- Referrals and transportation for out-of-state procedures,
- Post-procedure care for out-of-state services such as transplants, when the patient is too medically fragile to return, and
- Referrals to the MassHealth Coordination of Benefits Unit for coordinating benefits with commercial insurances.