The Mass Health Prior Approval Process

 

The Mass Health Prior Approval process can be tedious and difficult to navigate without the right guide. That's where we come in. 
 
Check out our Frequently Asked Questions below
 
  • The process begins when your physician sends us the necessary paperwork so that we may apply to Mass Health.
  • Once they've sent us EVERYTHING that is required by Mass Health, we apply to Mass Health electronically, via their Provider On-line Service Center. (See Insurance Information for requirements to apply)
  • Once Mass Health has received our request, they have 14 business days to make a determination (due to weekends and holidays, this typically translates into 2-3 weeks)
  • They may do 1 of three things:

        1. Approve

        2. Deny

        3. Modify

  • They will send you, the member, a Decision Notice at the same time that they send us a Decision Notice.
  • If they APPROVE, we will contact you if you need to choose nutritional flavors or confirm your address and we will send out your first order immediately.
  • If they DENY, we will notify your physician or whoever sent us the initial request (case worker, dietician, nurse, etc.) to let them know what is going on.
  • If they MODIFY the decision, we will proceed to contact you to setup your delivery or we will contact the referring physician if there is an issue with the items that were authorized.

 

If you have received your decision notice and aren't sure what was approved or have any questions, please contact us. If you want to check the status of a request, please contact us.

 
Frequently Asked Questions
 
Q: What is a Mass Health Prior Authorization?
A: A prior authorization is just what it sounds like-- its a PRE-authorization which means they've agreed that the requested services are medically necessary, but they will not agree to cover (aka pay for) the services if member eligibility or any other prerequisites are not met at the time the service is rendered.
 
Q: How long does it take to get a Mass Health prior authorization?
A: Once Mass Health receives our application, they have 14 business days to make a decision. This usually translates into 2-3 weeks. Call us anytime (508-865-4857) or send us an e-mail (customer.service@allcaremed.org) to check the status.
 
Q: Why does it take SOOOOOO long to get the authorization?
A: 90% of the time the delay is in getting the correct documentation from the doctor's office. To cut down on these delays, make sure that your doctor's office knows what we need! Check out the links to printable checklists for documentation requirements and insurance information in Insurance Information.
 
Q: What if I was denied by Mass Health?
A: You have 2 options you may pursue: 1. Appeal Mass Health's decision by following the instructions given on your Decision Notice from Mass Health. 2. Re-apply for authorization by asking your doctor to send additional information to apply again.
 
Q: How long is my authorization good for?
A: We will apply for the full length of time that the doctor prescribes, however Mass Health may choose to approve a shorter length of time based on their review of the clinical documentation. They will not approve more than a 1 year time period however. You can find the Expiration Date listed on the Decision Notice that Mass Health mails to you (the member).
 
Q: I received my Mass Health Decision Notice and the items were approved. Now what happens?
A: We should receive the Decision Notice around the same time as you, and when we do so, we will contact you to schedule your first delivery or, if we already have your address and do not need to get any additional information from you, we will send out your first order right away. You can call us any time to check the status of an order. 
 
Q: What if my insurance changes while my Prior Authorization is still pending?
A: If you are no longer eligible for Mass Health, you can not receive services, even if they give a Prior Authorization. Remember, that PA is pending member eligibility, so if you're not eligible, you can not receive any services.
 
Call Mass Health Customer Service if you have any questions about your Mass Health eligibility. Visit Mass Health Customer Service Contact Info or call MH customer Service at 800-841-2900
 
If you switch your existing Mass Health insurance coverage to a Managed Care Organization (MCO) such as Network Health, BMC Healthnet or Neighborhood Health Plan, then please contact us right away so we can send the application to the appropriate Health Plan. Sometimes these MCO plans require different documentation than the standard Mass Health plans, so please contact us ASAP so we can request any required additional information from your doctor.
 
Q: What if I no longer need the supplies that my doctor requested?
A: Please call us to let us know you'd no longer like to receive those items. If you need a different item, we will need to apply for a new prior authorization for the new item. Unfortunately, Mass Health will not adjust the existing authorization to be for a different item.
 
Q: How soon should I apply for a new authorization when my current authorization expires?
A: Its a good idea to start gathering the necessary paperwork at least a month before the expiration date. This way there will be plenty of time left to get all the correct documentation and get a decision from Mass Health before your current auth expires. We can apply for a start date in the future, so as soon as you have the new paperwork, Contact Us, give us a call at 508-865-4857 or fax the paperwork to us at 508-865-6370. We can apply up to 2 months ahead of the expiration date.
 
Q: How often can I get an order?
A: Orders can be placed once a month. There usually needs to be 30 days in between each order. That means, if you got your order on the 10th this month, you can get your next order on the 10th of next month. But don't wait til the last minute to call for your order. Call us a week ahead to ensure that you receive your order when you need it.
 

Please do not hesitate to contact us if there are any questions

we've left unanswered.

We welcome all feedback!