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Click ‘Get Form’ to open the MassHealth Prior Authorization Request in the editor.
Begin by filling out the Provider Information Section. Enter your name, address, and phone number in Item 1, followed by your Provider ID or NPI in Item 2. Select the type of PA you are requesting in Item 3.
Next, complete the Member Information Section. Fill in the member’s details in Item 4 and indicate if they are enrolled in Community Case Management in Item 13.
In Item 14, provide a detailed explanation of why the service is medically necessary, including diagnosis and treatment description.
Proceed to the Services Requested Section. Enter service codes and units for each requested service in Items 16 and 17 respectively.
Finally, check if any attachments are needed in Item 18 and ensure you sign the form in Item 22 to certify its accuracy before submission.

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