Form Pa-1 - Prior Authorization Request - Masshealth

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Prior Authorization Request
MassHealth reviews requests for prior authorization on the basis of medical necessity only. If MassHealth
approves the request, payment is still subject to all general conditions of MassHealth, including current
member eligibility, other insurance, and program restrictions. MassHealth will notify the provider and
Commonwealth of Massachusetts • EOHHS
member of its decision. Providers must complete items 1-21 or risk delays.
PROVIDER INFORMATION SECTION
MEMBER INFORMATION SECTION
1. Provider’s Name, Address, and Tel. No.
4. Member’s Name, Address, and Tel. No.
5. Place of Residence
Home
Nursing facility
Rehab. Hospital
Other:
_______________
6. Height
7. Weight
ft
in
lb
oz
2. Provider ID/Service Location or NPI
8. Gender
9. Other Insurance 10. Full Name of Insurance Carrier
M
F
Yes
No
3. PA Assignment
11. Date of Birth
12. Member ID
/
/
13. Explain why this service is medically necessary. Include the diagnosis, place of service, and a description of the proposed treatment. Attach supporting documentation if required by MassHealth regulations.
Primary Diagnosis
Secondary Diagnosis
Diagnosis Code(s)
Place of Service
Description of Treatment
MASSHEALTH USE ONLY (ITEMS 22-38)
SERVICES REQUESTED
14.
15.
16. No.
23.
24.
25.
26.
27.
28.
Servicing Provider
Service Code (Use a separate line for
of Units
Reviewer
Revised Service
No. of Units
Duration
Unit Fee
Denial Reason
each code.) Include modifier if
(Enter at
Decision
Code (or Range)
(Days)
No.
ID/Service Location or NPI
code requires one.
least 1.)
Approved
Modified
A
Denied
Approved
Modified
B
Denied
Approved
Modified
C
Denied
Approved
Modified
D
Denied
Approved
Modified
E
Denied
29. Receipt Date
30. Deferral Date
31. Date Info Received
17. Attachments
18. Date PA Requested
Yes
No
/
/
/
/
/
/
/
/
32. Authorized Effective Date
33. Authorized End Date
34. Decision Date
19. Requested Effective Date
20. Requested End Date
/
/
/
/
/
/
/
/
/
/
35. Consultant Initials
36. Consultant ID
21. Provider Signature
I certify that I am the provider identified on this form. I certify that the information provided on this form
and on any attachments, including medical necessity information (per 130 CMR 450.204) is true, accurate,
and complete to the best of my knowledge. I understand that I may be subject to civil penalties or criminal
37. Tracking Number
prosecution for any falsification, omission, or concealment of any material fact contained herein.
22. Comments for reason of denial, modification, or deferral
(MASSHEALTH USE 0NLY)
38. PA Number
P
Please see reverse side for instructions.
PA-1 (Rev. 08/15)

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