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Masshealth standard prior authorization form

Masshealth prior authorization 2025

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4.8 out of 5

148 votes

The document outlines the process for submitting a General Drug Prior Authorization Request to MassHealth, focusing on medical necessity for medication approval. It includes sections for member and medication information, billing preferences, previous medication trials, and medical necessity explanations. Additionally, it highlights specific requirements for pediatric behavioral health medications and provides instructions for prescribers to certify the accuracy of the information provided.

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Click ‘Get Form’ to open the MassHealth Prior Authorization Request in the editor.
Begin by filling out the member information section. Enter the last name, first name, middle initial, MassHealth member ID, date of birth, and gender.
In the medication information section, specify the medication requested along with its dose, frequency, and duration. Clearly state the indication for this medication.
Proceed to Section I. Indicate your billing preference (Pharmacy, Prescriber in-office, or Hospital outpatient) and provide the Drug NDC if known.
Answer whether the member has tried other medications for this condition. If yes, provide details including drug names and any adverse reactions experienced.
In Section II, explain the medical necessity of the requested drug and list all current medications along with any relevant diagnostic studies performed.
Complete Section III if requesting a non-preferred drug product by providing justification for its necessity over preferred options.
Finally, fill out prescriber information and ensure to sign and date where indicated to certify accuracy.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (148 Votes)
2017	4.3 Satisfied (68 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How long does prior authorization take for medication at MassHealth?

It typically takes 24 to 72 hours. You may check the status of your prior authorization request on the prior authorizations page. You may also contact your doctors office directly.

How to get prior authorization for medication MassHealth?

You may be able to speed up a prior authorization by filing an urgent request. If you cant wait for approval, you may be able to pay upfront at your pharmacy and submit a reimbursement claim after approval.

How long does a medication prior authorization take?

How to request You can use our Prior Authorization Forms for Pharmacy Services page to find the right PA form. Search for the right form by either: You can also go directly to the MassHealth Drug List A - Z tool to search by drug name. You can also search for the right forms by using the Therapeutic Class Tables.

How can I speed up my prior authorization for medication?

At the federal level, earlier this year the Centers for Medicare and Medicaid Services (CMS) issued a final rule that will, among other things, require payers to send prior authorization decisions within 72 hours for urgent requests and within a week for nonurgent requestsstarting in 2026.

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Facts about masshealth prior authorization

The MassHealth Prior Authorization form is essential for healthcare providers seeking approval for specific medications based on medical necessity, ensuring that patients receive the appropriate treatments covered by MassHealth.

Use cases of the form

Form filing requirements

How to submit the masshealth prior authorization?

Other important aspects to understand about completing masshealth prior authorization

Use cases of the form

This form is primarily required by healthcare providers, including physicians and pharmacists, who are submitting requests for medication prior authorization on behalf of their patients. It is particularly relevant for prescribers dealing with pediatric patients under the Pediatric Behavioral Health Medication Initiative, where certain medications require additional scrutiny due to safety and efficacy concerns in younger populations. Additionally, it serves those managing complex cases involving polypharmacy or non-preferred drug products.

Form filing requirements

To successfully file the MassHealth Prior Authorization form, providers must ensure they meet specific criteria such as current member eligibility and adherence to program restrictions. The request must be submitted promptly to avoid delays in patient care, typically within a designated timeframe set by MassHealth policies.

Ensure all sections of the form are completed accurately.
Attach any necessary supporting documentation like medical records.
Submit the request before the medication is needed to allow for processing time.

How to submit the masshealth prior authorization?

Submitting the MassHealth Prior Authorization form involves several steps: first, obtain the latest version of the form from DocHub or directly from MassHealth's website. Next, fill out all required fields meticulously, ensuring that all necessary documentation is attached. Finally, submit your completed form either via fax or through an online submission portal if available.

Download the MassHealth Prior Authorization form from DocHub or www.mass.gov/druglist.
Complete all sections of the form with accurate patient and medication information.
Gather any required supporting documents such as medical records.
Fax the completed form and documents to (877) 208-7428 or submit through an online portal if applicable.

Other important aspects to understand about completing masshealth prior authorization

It is crucial for providers to keep a copy of submitted forms for their records. Additionally, understanding that approval does not guarantee payment until all conditions are met can help manage expectations. Providers should also be aware of potential civil penalties for falsifying information on these forms.

MassHealth reviews requests based solely on medical necessity.
'Black ink' is recommended when faxing forms to ensure clarity.
'Preferred drug products' may exist within classes requiring justification for non-preferred requests.