Obtain PA before first service; interim PA allowed up to 60 days

Initial prior authorization must be obtained before the first day of Day Habilitation services. Providers may request an interim (temporary) authorization for up to 60 days to allow completion of the Service Needs Assessment and Leveling Tool. Reauthorization requests must be submitted at least 14 calendar days before the current authorization expires.

• Initial Authorization: obtained before the first day of service.
• Interim Authorization: temporary PA up to 60 days for completion of SNA and Leveling Tool.
• Reauthorization: submit renewal ≥14 calendar days before expiration.

New PA required for significant status changes or provider transfers

Submit a new prior authorization when a member has a significant change in status that affects functioning or when the member transfers to a different Day Habilitation provider (excluding internal program shifts).

• Significant Change in Status: new PA required for substantial changes in health affecting functioning.
• Provider Transfer: new PA required when member moves to a different Day Habilitation provider (except internal shifts).

Authorization must follow program-specific rules (PACE, Medicare Advantage, MassHealth)

Follow program-specific authorization processes: PACE members require authorization by the interdisciplinary team (except emergency or out-of-area urgent care); Medicare Advantage determinations follow applicable NCDs/LCDs and Medicare rules (with Fallon internal criteria only where Medicare criteria are not established); MassHealth members follow MassHealth Medical Necessity Guidelines.

• PACE: All care/services must be authorized by the interdisciplinary team (except emergency/out-of-area urgent care).
• Medicare Advantage: comply with applicable NCDs/LCDs and Medicare statutes/regulations; Fallon may apply internal criteria only where Medicare criteria are not fully established.
• MassHealth: follow MassHealth Medical Necessity Guidelines; Fallon may create criteria only where MassHealth guidelines are absent.

Align PA and service plan to SNA/Leveling Tool; authorizations up to 2 years

Ensure authorizations and service planning align with the member's assessed level of need determined by the Day Habilitation Leveling Tool and Service Needs Assessment; members may be approved for services for up to two years based on medical necessity and assessed level.

• Use SNA and Day Habilitation Leveling Tool to determine appropriate staffing/support and authorization level.
• Authorizations may be issued for up to two years based on medical necessity and assessed level of need.

Follow interim PA and reauthorization administrative timelines

Follow administrative rules for authorization timing and transfers: submit interim PA requests when enrolling a member to allow completion of assessments, and submit renewal requests at least 14 calendar days before expiration to avoid lapse of authorization.

• Interim PA: request when member enrolls to permit SNA/Leveling Tool completion.
• Reauthorization: submit ≥14 calendar days before current authorization end date to maintain continuity.
• Provider transfers: new provider must submit PA per interim authorization guidelines.

Submit required documents with PA requests

Include all required documentation with PA requests: written PCP diagnosis of intellectual or developmental disability; Fallon Health PA request form; completed Service Needs Assessment (SNA); Day Habilitation Leveling Tool; current Day Habilitation Service Plan (DHSP); hospice non-duplication statement when applicable; Level II PASRR for nursing facility residents; and any supporting behavior or clinical documentation.

• Written diagnosis from PCP of intellectual or developmental disability.
• Fallon Health standardized PA request form.
• Completed Service Needs Assessment (SNA).
• Day Habilitation Leveling Tool.
• Current Day Habilitation Service Plan (DHSP).
• Hospice signed non-duplication statement (if hospice-enrolled).
• Level II PASRR (for nursing facility residents).
• Any additional supporting materials (behavior support plans, clinical documentation).

Medicare Advantage NCDs/LCDs and Fallon/MassHealth requirements for determinations

For Medicare Advantage members, adhere to applicable NCDs and LCDs and Medicare statutes/regulations when requesting medical necessity; Fallon may apply internal criteria only when Medicare criteria are not fully established. For MassHealth members, follow MassHealth Medical Necessity Guidelines (or create Fallon criteria only if MassHealth guidelines are absent).

• Medicare Advantage: follow CMS NCDs/LCDs and Medicare law/regulation; Fallon internal criteria used only where Medicare criteria lack specificity.
• MassHealth: follow MassHealth Medical Necessity Guidelines; Fallon creates criteria only if none exist.

Services without approved PA will not be covered

Services provided without an approved prior authorization will not be covered. Do not bill for services delivered outside an active, approved PA.

• Missing PA: services without approved prior authorization are not payable.

Canceled sessions are not billable and are non‑reimbursable

Canceled Day Habilitation sessions are not billable and will not be reimbursed. Providers must not submit claims for scheduled sessions that were canceled.

• Canceled Sessions: not billable; no reimbursement.

Benefit plan exclusions and limitations may override policy

Coverage is governed by the member's specific benefit plan; services may be denied if the benefit plan excludes Day Habilitation or contains other limitations. If the benefit plan provisions differ from this policy, the benefit plan governs except where state or federal mandates apply.

• Consult the member's Evidence of Coverage for plan-specific exclusions or limitations.
• If a discrepancy exists between this policy and the benefit plan, the benefit plan provisions govern (subject to applicable state/federal mandates).