CurrentMass General Brigham Health PlanPolicy N/A

Medicare Advantage Prior Authorization and Notification Guidelines

Governs which services require prior authorization or notification for Mass General Brigham Health Plan Medicare Advantage members and how authorizations are reviewed; applies to providers delivering services to those members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedicare Advantage Prior Authorization and Notification Guidelines

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility and the existence of an authorization via the Mass General Brigham Health Plan Provider Portal before scheduling services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Manyservices enumerated with PA requirements

24h/next BDemergent inpatient notification timing

20 visitsOT/PT—no PA for first

CT/MRI/PETnon-emergent outpatient imaging PA

YesPA required for select services

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Coverage and Prior Authorization Rules

General prior authorization and review criteria

Prior authorization is required when specified in the plan chart and when LCD/NCD or InterQual criteria apply.

PA determination: PA is required for listed services; clinical review will use LCD/NCD or InterQual when available, otherwise Mass General Brigham Health Plan medical policy

Applies to services enumerated in the document

Outpatient high‑technology radiology studies such as CT, MRI and PET performed in a non‑emergent, outpatient setting do require prior authorization. However, prior authorization is not required for MRI, CT & PET imaging studies performed in an inpatient setting or through emergency care in the ER. When a code requires prior authorization, Mass General Brigham Health Plan will review using LCD/NCD or InterQual criteria when available; if none exist, the Plan’s medical policy will be used.

Prior authorization for prosthetic devices is required in some cases; the requirement depends on the type of prosthetic. For prosthetic items and codes that require PA, Mass General Brigham Health Plan will apply LCD/NCD or InterQual criteria when available, and otherwise will apply the Plan’s medical policy. Providers should consult the Plan’s provider resources for the formal list of prosthetic types and the PA submission requirements.

Coding, Visit Thresholds, and Timing

Services referenced (codes not listed in this part)mixed

No codes listed

OT/PT visit threshold — outpatient/home

ThresholdNo prior authorization required for the first 20 outpatient or home occupational and physical therapy visits; prior authorization required after 20 visits.

Applies toOutpatient and home Occupational Therapy and Physical Therapy services (see Home Health Services for home occupational therapy).

Review criteriaWhen PA is required, Mass General Brigham Health Plan will use LCD/NCD or InterQual criteria; if none exist, the plan's medical policy will be used.

Emergent inpatient notification timing

Timing requirementFor emergent inpatient admissions, authorization/notification is required within 24 hours or by the next business day.

Concurrent reviewConcurrent authorization is required for additional inpatient days following the initial authorization as per the next review date/last covered day.

What Providers Must Do

Denial Risk

Verify eligibility and authorization

Verify member eligibility and any existing authorizations before scheduling or providing services. Prior authorization is not a guarantee of payment; failure to obtain required authorization may result in denial of payment.

Check authorizations via the Mass General Brigham Health Plan Provider Portal.
For behavioral health services contact Optum as applicable.
Contact Mass General Brigham Health Plan Medicare Advantage: 844-357-0946.

Denial Risk

Timing risk for emergent admissions

For emergent inpatient admissions, notify the plan and obtain authorization within 24 hours or by the next business day. Concurrent authorization is required for continued inpatient days per the next review date/last covered day to avoid risk of denial.

If authorization/notification is not provided within the required timeframe, payment may be denied.
Concurrent review requirements apply for additional inpatient days.

Policy Background and Scope

This administrative guideline describes the prior authorization and notification expectations for Mass General Brigham Health Plan Medicare Advantage providers. It enumerates services that typically require prior authorization or inpatient notification and explains how clinical review will be conducted.

For services listed as requiring prior authorization, the Plan will use LCD/NCD or InterQual criteria where available; if no relevant LCD/NCD or InterQual criteria exist, the Plan’s medical policy will be used for determination. Providers must verify member eligibility and any existing authorization through the Mass General Brigham Health Plan Provider Portal prior to scheduling services.

The guideline also specifies timeframes for inpatient emergent notifications: when an authorization/notification is required for an emergent inpatient admission, notification must occur within 24 hours or by the next business day. Failure to obtain required prior authorization or to meet notification timing may put payment at risk.

Key Definitions

Hospital at Home (HaH) definition and components

DefinitionHospital at Home (HaH), also known as Hospital in the Home (HITH), is an acute inpatient admission delivered in the member's home and requires inpatient authorization for adult acute HaH admissions.

Included componentsIncluded services may include transportation, durable medical equipment (DME), oxygen, IV infusion, and MD/RN services.

Authorization noteThis inpatient authorization covers the Acute Inpatient Admission at Home and included services; no additional authorization is required for services included under the HaH authorization.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedicare Advantage Prior Authorization and Notification Guidelines

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility and the existence of an authorization via the Mass General Brigham Health Plan Provider Portal before scheduling services.

SourceLink

On This Page

Risk of non-complianceFailure to notify within the required timeframe may risk denial or non-compliance with plan requirements.

Initial outpatient therapy visit limit without PA

Initial visit allowanceNo prior authorization required for the first 20 outpatient therapy visits (physical, occupational, and speech therapy).

When PA becomes requiredPrior authorization is required after the initial 20 visits for outpatient PT/OT/speech therapy.

Scope noteSee Home Health Services for home-based therapy; plan uses LCD/NCD or InterQual criteria for PA review when available.

Prior Authorization

Hospital at Home authorization

Adult acute Hospital at Home (HaH) admissions require an inpatient authorization. The inpatient HaH authorization covers included services (for example: transportation, DME, oxygen, IV infusion, MD/RN services) and no additional authorization is required for those included services.

Hospital at Home (HaH) = inpatient authorization for Adult Acute HaH admissions.
Included services under the HaH authorization: Transportation, DME, Oxygen, IV infusion, MD/RN services. No separate authorization required for included items.

Prior Authorization

Radiation Therapy (outpatient) — Prior authorization required

Outpatient radiation therapy requires prior authorization. Use applicable LCD/NCD, InterQual criteria, or Mass General Brigham Health Plan medical policy when external criteria are not available.

Radiation Therapy (outpatient) — Prior authorization required.
Review LCD/NCD/InterQual first; if none exist, follow Mass General Brigham Health Plan medical policy.

Prior Authorization

Sleep services — prior authorization required

Sleep-related services (sleep studies, PAP devices, and surgical treatment for OSA) require prior authorization and are reviewed using CareCentrix clinical criteria where applicable. Failure to obtain required authorization may lead to denial of payment.

Sleep studies — Prior authorization required; see CareCentrix Clinical Criteria.
PAP therapy devices — Prior authorization required; follow criteria for diagnosis and treatment of sleep disordered breathing.
Surgical treatment for OSA — Prior authorization required; CareCentrix Provider Service: 866-827-5861.

Note

Review criteria sources

For services that require clinical review, the plan uses LCD/NCD or InterQual criteria. When no LCD/NCD or InterQual criteria exist, Mass General Brigham Health Plan medical policies apply. Refer to the plan's medical policies and specialty drug policies for details.

Primary review sources in this order: LCD/NCD → InterQual → Mass General Brigham Health Plan medical policy.
Refer to Medical Policies and Medical Specialty Drug Policies on the provider portal for specific clinical requirements.

Note

Supportive references for specific services

Supportive resources and references: use the Mass General Brigham Health Plan Provider Portal to enter and verify prior authorizations. For Part B drugs and imaging PA requirements, refer to the plan’s Part B drug resources and eviCore/AIIWays Health Partners imaging guidance as referenced in plan materials.

Mass General Brigham Health Plan Provider Portal for PA entry and verification.
Part B drug reference pages (see plan links) for drugs that require PA.
eviCore / AIIWays Health Partners resources for CPT codes subject to prior authorization and clinical guidelines for imaging.