How to Fill Out and Submit the MassHealth PCA Application (PCA-1)

The MassHealth PCA-1 application is filed by a Personal Care Management (PCM) agency on your behalf to request prior authorization for Personal Care Attendant services. You supply most of the personal, household, and service information the form asks for, and you participate in an in-home nursing evaluation (documented on a separate form, the PCA-2) that determines the weekly hours MassHealth authorizes. Your PCM agency assembles the PCA-1, the PCA-2, a prior authorization request, and supporting clinical documents, then sends the package to the MassHealth Long Term Services and Supports (LTSS) unit for review.

Do You Qualify to Apply

Four conditions have to be met before a PCM agency will start a PCA-1 for you. You need MassHealth Standard or CommonHealth coverage, or enrollment in a Senior Care Options or One Care plan. Your disability must be permanent or chronic and must impair your ability to perform daily activities without physical, hands-on help. You must need physical assistance with at least two Activities of Daily Living. And MassHealth itself must determine that PCA services are medically necessary.¹

The seven ADL categories MassHealth recognizes are mobility, medication assistance, bathing or grooming, dressing, passive range-of-motion exercises, eating, and toileting. Needing hands-on help with any two of those because of a chronic condition clears the threshold for applying.¹

Start By Contacting a PCM Agency

You can’t submit a PCA-1 yourself. A MassHealth-contracted PCM agency handles the application, coordinates the nursing evaluation, and files everything with MassHealth. MassHealth publishes a full list of PCM agencies with addresses and phone numbers covering every region of the state.²

Once you reach out, the agency runs an intake and orientation, collects your basic information, explains how the program works, and schedules the in-home evaluation. Under the regulations, the PCM agency must submit the initial prior authorization request to MassHealth within 45 calendar days of your first inquiry.³

If you need materials in braille, large print, or other languages, or have general questions about the program, call the MassHealth Customer Service Center at (800) 841-2900 (TDD/TTY: 711).²

What Information You Provide on the PCA-1

The PCA-1 collects demographic, household, and service information. It does not contain the clinical evaluation or functional scoring; that goes on the PCA-2 during the RN home visit.⁴

PCM Agency Section

Your PCM agency completes this section itself: its name, MassHealth provider number, and requesting contact’s phone and fax. The agency also marks whether the request is standard or expedited. Expedited review is available when a delay could seriously jeopardize your health, and the agency has to explain the urgency in writing.⁴

Consumer Information Section

This is the longest section, and most of it comes from you. Expect to provide your 12-digit MassHealth ID number (from your MassHealth card), date of birth, age, full name, address, and phone number.⁵ You’ll also be asked for:

Your legal guardian’s name, address, and phone number, if you have one.
The physical address where you’ll receive PCA services. A P.O. box is not acceptable.
Your living arrangement (assisted living, group home, with family, independently, or other) and who lives with you.
Whether you receive residential services from a state or federal agency such as DDS, DMH, DCF, or MRC.
The names of anyone else in your household who receives MassHealth PCA services.
For new applicants, the date you first contacted the PCM agency and the event that prompted your request.

If you’re applying for a reevaluation rather than a first-time authorization, this section also captures your current prior authorization number, whether it was authorized for two or more years, and your current authorized day, evening, and overnight hours per week.⁴

Current Health-Related Services Section

The PCA-1 asks whether you currently receive, or are about to start receiving, any of more than a dozen other services: home health aide visits, skilled nursing, respite care, elder services, hospice, homemaker services, meal delivery, adult day health, day habilitation, and others. For each one, the form asks whether it will continue after PCA approval and who pays for it. This helps MassHealth coordinate your care and avoid duplicating services.⁴

The In-Home RN Evaluation (PCA-2)

The PCA-2 is the clinical companion to the PCA-1, and it drives the number of hours MassHealth authorizes. A Registered Nurse from your PCM agency schedules a visit at your home. The evaluation must be conducted where you live, and you (and your surrogate, if you have one) must be present. An occupational therapist attends the first evaluation and may attend reevaluations as well.⁶

During the visit, the RN scores your functional abilities across each ADL and IADL. For each activity (mobility, bathing, dressing, toileting, eating, medication assistance, and range-of-motion exercises), the evaluator records a level of assistance: independent, minimum, moderate, maximum, or total dependence. The RN also evaluates your Instrumental Activities of Daily Living, which cover household tasks like laundry and housekeeping, meal preparation, transportation to medical appointments, and special needs like wheelchair maintenance. Your primary diagnosis (the chronic condition that prevents you from performing daily activities without hands-on help) is recorded as well.⁷

Have your medications and a prescription list ready for the visit, because the RN will review medication administration details. If you need PCA time for transportation to medical appointments, be prepared to give the type of provider, the provider’s name, the town, and how often you go per year. The RN counts travel and assistance time only, not wait time at the appointment.⁶

After the home visit, the RN recommends a weekly hour figure and sends the completed evaluation to your primary care physician or nurse practitioner, who reviews it, signs it, and returns it to the PCM agency. The agency then bundles it with the PCA-1 and supporting documents for submission.⁶

Supporting Documents That Must Ride With the PCA-1

The PCA-1 and PCA-2 by themselves aren’t enough. The full prior authorization package must also include a completed MassHealth Prior Authorization Request form and clinical documentation that identifies a permanent or chronic disability and confirms your need for physical assistance with at least two ADLs.³

A PCP Summary Form may also be required, where your physician lists the diagnoses affecting your functional abilities. The form uses ICD-10 diagnostic codes in its complex care section.⁸

The package must also include a completed and signed assessment of your ability to manage the PCA program independently. That assessment decides whether you can direct your own care or need a surrogate to manage the program on your behalf.³

Missing pieces are the most common reason packages get sent back. Before your PCM agency submits, confirm every form is complete and your PCP has signed the evaluation.

How the Package Is Submitted

The completed PCA-1, PCA-2, prior authorization request, and supporting documents go to the MassHealth LTSS Provider Service Center. Your PCM agency can submit by mail, fax, or through the LTSS Provider Portal online.⁹

Mail: MassHealth LTSS Provider Service Center, PO Box 159108, Boston, MA 02215
Fax: (888) 832-3006
Online: LTSS Provider Portal at masshealthltss.com

The prior authorization request has to include the provider number of the fiscal intermediary selected by your PCM agency. All forms must be submitted on official MassHealth forms and follow the billing instructions in the Personal Care Manual.³

For reevaluations, the PCM agency must submit the request at least 21 calendar days before your current authorization period expires to avoid a gap in services.

After Submission: Decision and Appeal

MassHealth reviews the package and issues a written decision notice. If the request is approved or modified, the notice specifies the number of PCA hours per week MassHealth considers medically necessary and the duration of your prior authorization period. If the authorized hours are fewer than the evaluation recommended, or the request is denied outright, the notice explains why and includes information about your appeal rights.³

You have 60 calendar days from the date you received the decision notice to request a fair hearing through the MassHealth Board of Hearings. If you never received a written notice, the deadline extends to 120 calendar days from the date the action occurred.¹⁰

You can file the appeal several ways:

By mail: Board of Hearings, Office of Medicaid, 100 Hancock Street, 6th Floor, Quincy, MA 02171. Send the completed Fair Hearing Request form with a copy of the notice.
By fax: (617) 887-8797.
By email: boh-fairhearingsrequest@mass.gov.
By phone: MassHealth Customer Service Center at (800) 841-2900 (TDD/TTY: 711) to complete the form over the phone.¹⁰

1
MassHealth. 130 CMR 422.000 Personal Care Attendant Services Regulations
2
MassHealth. Personal Care Management (PCM) Agency List
3
Legal Information Institute. 130 CMR 422.416 – PCA Program: Prior Authorization for PCA Services
4
MassHealth. MassHealth PCA-1 Application for PCA Services
5
MassHealth. All Provider Bulletin 191 – New MassHealth Member ID Card
6
Tempus Unlimited. PCA Program Evaluation Documents
7
MassHealth. MassHealth PCA Evaluation Time-for-Task Tool
8
MassHealth. MassHealth Personal Care Attendant PCP Summary Form
9
MassHealth. Request Prior Authorization for Personal Care Attendant (PCA) Services
10
MassHealth. Fair Hearing Request Form