Form Pa-1 - Prior Authorization Request - Masshealth Page 2
ADVERTISEMENT
1
2INSTRUCTIONS FOR COMPLETING THE PA-1 FORM (PLEASE PRINT OR TYPE.)
General Instructions
Complete Items 1 - 21 only. Enter all dates in mm/dd/yyyy format. Below are instructions for specific fields. All other fields are self-explanatory.
(A) Provider Information Section
Item 1
Provider’s Name, Address, and Tel. No. Enter the provider’s name, address, and phone number (including area code).
Item 2
Provider ID/Loc or NPI
Enter the nine-digit requesting provider ID followed by the one-character location code.
If not available, enter the requesting provider’s 10-digit national provider identifier.
Item 3
PA Assignment
Select the type of PA you are requesting from the following list.
Basic Medical
Durable Medical Equipment
Therapy Services
Medical Pharmacy
Absorbent Products
Occupational Therapy
DMR PCA Services
DME – Other
Physical Therapy
PCA Services
Enterals
Speech/Language Therapy
Pediatric PCA Services
Hearing Services
PERS
Mobility and Repairs
Physician-Adult
Orthotics and Prosthetics
Physician-Pediatric
Oxygen
Private Duty Nursing
Standers
Skilled Nursing
Vision
Other
(B) Member Information Section
Item 4
Member’s Name, Address, and Tel. No. Enter the member’s name, address, and phone number (including area code).
Item 13
Explain why this service is medically
Enter a statement explaining why the proposed service is medically necessary. Include the primary diagnosis and
necessary
secondary diagnosis if there is one. Also include a description of the proposed treatment and prognosis. Refer to your
MassHealth provider manual for additional information about this field.
Diagnosis Code(s)
Enter the ICD diagnosis code(s) for the most relevant diagnoses for the procedure or item being requested.
Place of Service
Enter the location of service.
Description of Treatment
Enter a narrative of the proposed treatment.
(C) Services Requested Section
Item 14
Servicing Provider ID/Service Location
Enter the nine-digit servicing provider ID followed by the one-character service location code. Write “same” if same as
or NPI
requesting provider ID/Service Location. If not available, enter the provider’s 10-digit national provider identifier.
Item 15
Service Code
Enter the appropriate CPT or HCPCS code for each service requested. Refer to Subchapter 6 of the applicable MassHealth
provider manual to determine payable service codes. You must include a modifier if the service code requires one.
Item 16
No. of Units
Enter the number of times the service for which you are requesting prior authorization will be furnished. At least “1” must
be entered.
(D) Attachments and Signature
Item 17
Attachments
Select the “Yes” box if additional information or supporting documentation is attached (refer to your provider manual);
otherwise select the “No” box. Be certain that the attached documentation clearly supports the medical necessity for the
services and/or equipment you are requesting (for example, X rays, admission notes, photographs, or explicit details).
Item 21
Provider Signature
The form must be signed by the provider or the individual designated by the provider to certify that the information
entered on the form is correct. Signatures other than handwritten (that is, typewritten, or those by stamp or data
processing equipment) are acceptable.
(E) MassHealth Use Only
Items 22 – 38
Leave these items blank.
MassHealth completes Items 22 – 38 when it reviews the request for prior authorization. Leave these fields blank.
See Subchapter 5 of your MassHealth provider manual for additional instructions for requesting prior authorization.
INSTRUCTIONS FOR MAILING REQUESTS FOR PRIOR AUTHORIZATION
Mail the Prior Authorization Request form, together with all necessary attachments, to:
MassHealth
ATTN: Prior Authorization
100 Hancock Street, 6th Floor
Quincy, MA 02171
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal