Prior Authorization

Prior authorization, also called prior approval, means getting permission from your child's health plan before your child uses a special service or kind of equipment. It is usually the responsibility of your child's primary care provider (PCP) or other treating provider to get prior authorization from the health plan.

Examples of services usually requiring prior authorization are:

• Most hospital admissions
• Medical procedures
• (Non-emergency) surgeries
• Some tests and consultations (such as a second opinion)
• Durable medical equipment (DME)
• Home healthcare
• Outpatient therapies (such as physical, occupational, and speech therapy)

Different plans have different prior authorization processes. Learn about the process at your child's health plan so you will know what to do if your child needs any services that require prior authorization. Call a member services representative or your child's case manager at the plan to learn more about the prior authorization process.

Medical Necessity

In some cases, your child's PCP will need to write a letter of medical necessity to the health plan. This letter states the medical reasons why your child needs a special service or equipment.

In Massachusetts, medical necessity is defined as follows:

Healthcare services that are consistent with the generally accepted principles of professional medical practice as determined by whether the service:

1. Is the most appropriate available supply or level of service for the insured in question considering potential benefits and harms to the individual;
2. Is known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes; or
3. For services and interventions not in widespread use, is based on scientific evidence.

MA Department of Public Health, Office of Patient Protection: 800-436-7757

This information is provided in part by the Division of Perinatal, Early Childhood, and Special Health Needs within the Massachusetts Department of Public Health and mass.gov.

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