CurrentMass General Brigham Health PlanPolicy N/A

Medicare Advantage Prior Authorization and Notification Guidelines

Overview of services that require prior authorization or notification for Mass General Brigham Health Plan Medicare Advantage members; guidance for providers on authorization processes and use of LCD/NCD, InterQual, or plan medical policy to review requests.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedicare Advantage Prior Authorization and Notification Guidelines

Policy CodePolicy N/A

Change TypeMinor / informational

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for listed outpatient non-emergent services (enter requests via the Mass General Brigham Health Plan Provider Portal).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Manylisted services with PA or notification requirements

24 hrsemergent inpatient notification timeframe

20 visitsOT/PT visits without PA

PA requiredHigh-tech radiology outpatient

8.15.2024document date

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Prior Authorization and Coverage Criteria

General PA review criteria

Services listed are subject to prior authorization when indicated; reviews use LCD/NCD or InterQual criteria, or the plan's medical policy if no external criteria exist.

General Review Process: Mass General Brigham Health Plan will use Local Coverage Determination (LCD) or National Coverage Determination (NCD) to review codes/services requiring prior authorization using InterQual criteria; if there are no LCD/NCD or InterQual criteria, the plan's medical policy will be used.

applies to all listed services

Advanced Imaging

Prior authorization required for outpatient non-emergent advanced imaging.

Outpatient CT/MRI/PET: Prior authorization is required for outpatient non-emergent CT, MRI, and PET studies for all members; prior authorization is not required for MRI, CT, and PET imaging performed in an inpatient setting or through emergency care in the ER.

applies to outpatient non-emergent high-tech radiology

Outpatient Therapy Visits

Outpatient therapy visit authorization rule.

PT/OT First 20 Visits: No prior authorization required for the first 20 outpatient physical therapy, occupational therapy, and related therapy visits (includes outpatient and homecare as noted); prior authorization is required for visits after 20.20 visits

applies to outpatient and homecare therapy services

High-tech radiology studies performed in an inpatient setting or for emergent care in the emergency department do not require prior authorization. Specifically, MRI, CT & PET imaging studies performed in an inpatient setting or through emergency care in the ER are excluded from prior authorization requirements; prior authorization is required only for outpatient non-emergent CT, MRI & PET studies (these outpatient studies are reviewed using LCD/NCD and InterQual criteria, or the Plan medical policy if no external criteria exist).

Non-emergent transportation services associated with Hospital at Home (HaH) care should follow the Hospital at Home prior authorization directives referenced elsewhere in this document. For non-emergent transportation needs related to Hospital at Home, providers must refer to the HaH PA guidance above the grid to determine authorization requirements and submission instructions.

Coding Rules and Visit Thresholds

OT/PT visit threshold — Prior authorization rule

ThresholdNo prior authorization required for the first 20 outpatient OT/PT visits; prior authorization required after 20 visits.

Applies toOutpatient and homecare occupational and physical therapy as noted.

Review criteriaRequests after 20 visits will be reviewed using LCD/NCD or InterQual criteria; if none exist, the plan medical policy applies.

Outpatient therapy visit threshold

ThresholdFirst 20 outpatient therapy visits do not require prior authorization; visits after 20 require prior authorization.

Services coveredPhysical Therapy and Occupational Therapy (outpatient).

Provider Responsibilities, Authorization Process, and Denial Risk

Prior Authorization

General prior authorization requirement

Prior authorization is required for many services listed in this document. Mass General Brigham Health Plan will use LCD/NCD or InterQual criteria to review codes/services requiring prior authorization. If no LCD/NCD or InterQual criteria exist, the Plan's medical policy will be used. Failure to obtain a required prior authorization may result in claim denial. For emergent inpatient admissions, notification/authorization is required within 24 hours or by the next business day; concurrent authorization is required for additional days.

Use LCD/NCD or InterQual where available; otherwise use Plan medical policy
Prior authorization is not a guarantee of payment
Emergent inpatient admissions: notify within 24 hours or next business day

Prior Authorization

High‑tech radiology prior authorization

Prior authorization is required for outpatient non‑emergent CT, MRI, and PET imaging studies. Imaging performed in the inpatient setting or through emergency care in the ER is exempt from outpatient PA.

Definitions and Program Notes

Hospital at Home (HaH) — definition and authorization

TermHospital at Home (HaH) — also known as Hospital in the Home (HITH).

PA requirementInpatient authorization is required for Adult admission to Acute Hospital at Home.

Included servicesIncludes, but is not limited to: Transportation, DME, Oxygen, IV infusion, MD/RN services.

Policy Background

This document is an administrative guide that lists customary services that require prior authorization or notification for Medicare Advantage members and explains which clinical coverage criteria will be applied when reviewing requests. Mass General Brigham Health Plan uses external sources such as LCD/NCD and InterQual criteria to evaluate prior authorization requests; if no external criteria exist, the Plan's medical policy will be used to determine medical necessity.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedicare Advantage Prior Authorization and Notification Guidelines

Policy CodePolicy N/A

Change TypeMinor / informational

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for listed outpatient non-emergent services (enter requests via the Mass General Brigham Health Plan Provider Portal).

SourceLink

On This Page

DocumentationPA determinations will use LCD/NCD or InterQual criteria; if none exist, the plan medical policy will be used.

Applies to outpatient non-emergent CT, MRI & PET
Inpatient and ER emergent imaging are exempt

Prior Authorization

PT/OT outpatient visit limits

Outpatient physical therapy and occupational therapy do not require prior authorization for the first 20 visits. Prior authorization is required for any visits after the 20th visit.

No PA required for first 20 outpatient PT/OT visits
PA required for visits after 20

Prior Authorization

Speech therapy outpatient PA threshold

No prior authorization is required for the first 20 outpatient speech therapy visits. Prior authorization is required for speech therapy after the 20th visit.

No PA for first 20 outpatient speech therapy visits
PA required after 20 visits

Prior Authorization

Preimplantation Genetic Testing prior authorization

Prior authorization is required for preimplantation genetic testing; reviews will follow LCD/NCD or InterQual criteria when available, otherwise Plan medical policy applies.

Preimplantation Genetic Testing requires PA
Use LCD/NCD or InterQual first; otherwise Plan medical policy

Prior Authorization

Prosthetics prior authorization

Prosthetic devices require prior authorization. The PA requirement and documentation vary by prosthetic type and applicable codes; reviews will follow LCD/NCD or InterQual criteria when available, otherwise Plan medical policy applies.

PA requirement depends on prosthetic type and codes
Use LCD/NCD or InterQual when available; otherwise Plan medical policy

Prior Authorization

Radiation therapy (outpatient) prior authorization

Outpatient radiation therapy requires prior authorization. Reviews will follow LCD/NCD or InterQual criteria when available; if none exist, the Plan medical policy will guide determinations.

Outpatient radiation therapy requires PA
Review using LCD/NCD or InterQual; otherwise Plan medical policy

Prior Authorization

Therapeutic lenses prior authorization

Therapeutic lenses require prior authorization. Requests are reviewed using LCD/NCD or InterQual criteria when available, otherwise Plan medical policy is applied.

Therapeutic lenses require PA
Review using LCD/NCD or InterQual; otherwise Plan medical policy

Prior Authorization

Sleep services prior authorization

Sleep services—including diagnostic sleep studies, PAP therapy devices, and surgical treatments for OSA—require prior authorization. Clinical criteria such as CareCentrix or other referenced criteria will be used to determine medical necessity.

Sleep studies require PA (see CareCentrix Clinical Criteria)
PAP devices require PA (see referenced criteria)
Surgical treatment for OSA requires PA; contact CareCentrix Provider Service: 866-827-5861

Prior Authorization

Transplants prior authorization

Transplant services require prior authorization for both the surgeon's office visit and the transplant surgery. Reviews will be conducted using LCD/NCD or InterQual criteria when available; otherwise the Plan's medical policy applies.

PA required for transplant surgeon office visits
PA required for transplant surgery (organ, bone marrow, stem cell)
Use LCD/NCD or InterQual where available; otherwise Plan medical policy

Note

Pre‑service checks and submission

Before scheduling services, providers should verify member eligibility, review Provider Payment Guidelines and the member's Evidence of Coverage, and confirm PA requirements via the Mass General Brigham Health Plan Provider Portal. Prior authorizations should be submitted through the Provider Portal; the rendering facility and physicians are strongly encouraged to verify authorization existence prior to service.

Check member eligibility, Provider Payment Guidelines, and Evidence of Coverage before scheduling
Submit PAs via Mass General Brigham Health Plan Provider Portal
Verify existence of authorization prior to rendering service