What are the possible decisions?
The consultants may make any of the following decisions on a PA request: • Approve the request — the request is authorized. Deny the request — the request is denied and MassHealth will not reimburse for the service. • Modify the request — the approval is for a service that is different in quantity or nature than that which was originally requested, but it was determined that the approved item is appropriate to meet the medical needs of the member. • Defer the request — the request cannot be adjudicated as additional information is needed to make a decision; the provider is asked to submit supporting documentation.
