MassHealth Prior Authorization Form (PA-1): Fields, Documentation, and Decisions

The MassHealth prior authorization form, known as the PA-1, is the standard request form providers use to get advance approval for nonpharmacy services covered by MassHealth. You complete it with provider and member identifiers, the diagnosis and procedure codes, a medical-necessity narrative, and supporting clinical records, then submit it through the Provider Online Service Center (POSC). Paper submission by fax or mail is allowed only if you have an approved electronic claims waiver on file. MassHealth aims to decide complete standard requests within 7 calendar days, and expedited requests within 72 hours.¹

When the PA-1 Is the Right Form

The PA-1 is used for nonpharmacy services that MassHealth has specifically flagged as requiring prior authorization in its billing instructions, program regulations, service-code lists, and provider bulletins.² Common categories include durable medical equipment and oxygen, orthotics and prosthetics, occupational, physical, and speech-language therapy, private-duty and skilled nursing, personal care attendant services, and certain vision services.

Two things the PA-1 does not cover. Drug prior authorizations run through the MassHealth Drug Utilization Review Program using the Drug List’s clinical criteria, not the PA-1.³ Dental services are administered by DentaQuest and follow a separate process.⁴

Filling Out the PA-1 Field by Field

If you submit through the POSC, the system populates many fields digitally and runs validation checks before accepting the request. If you are filing the paper version, every field matters. An incomplete form triggers a deferral and delays the decision.¹

Provider Information (Items 1–3)

Item 1 is the requesting provider’s name, address, and phone number. Item 2 is the provider’s nine-digit MassHealth provider ID plus one-character location code, or the ten-digit National Provider Identifier (NPI) if a MassHealth ID is not available. Item 3 is the PA assignment category. Pick the one that matches the service: basic medical, a DME subcategory (mobility and repairs, oxygen, orthotics and prosthetics, hearing services, absorbent products, enterals, standers), therapy, nursing, PCA, vision, medical pharmacy, or “other.”

Member Information (Item 4)

Enter the member’s name, address, and phone number, along with the 12-digit MassHealth identification number. Check the number against the member’s MassHealth card. A single transposed digit routes the request to the wrong file.

Medical Necessity and Service Codes (Items 13–16)

Item 13 is the heart of the form. Write a clinical narrative that explains why the service is medically necessary, with the primary diagnosis (and any relevant secondary diagnosis), the proposed treatment, and the prognosis. MassHealth defines a service as medically necessary when it is reasonably expected to prevent, diagnose, alleviate, correct, or cure a condition that endangers life, causes pain, or threatens to cause disability, and when no comparable, less costly alternative is available.⁵ Reviewers read this field closely. Write it in plain clinical language instead of pasting boilerplate.

Enter ICD codes for the most relevant diagnoses. Item 14 is the servicing provider’s ID or NPI; write “same” if the servicing and requesting providers are the same. Item 15 is the CPT or HCPCS code for each service, with any required modifiers. Verify the code against the service-code list in your provider manual. Item 16 is the number of units the service will be furnished. Enter at least “1.”

Attachments and Signature (Item 17)

Select “Yes” on Item 17 and attach records that directly support medical necessity: X-rays, admission notes, photographs, lab results, treatment plans, or similar documentation. The requesting provider or an authorized representative must sign and date the form.

Supporting Documentation That Holds Up

The narrative on the PA-1 is only as strong as the records behind it. Attach documentation that shows what has been tried, what the clinical picture looks like now, and why the requested service is the appropriate next step. MassHealth requires that medically necessary services be substantiated by records demonstrating both necessity and quality, and providers must make those records available to the agency on request.⁵

Durable medical equipment has an extra requirement. Certain DME items need a documented face-to-face encounter with a practitioner within the six months before the order. The record of that encounter must contain beneficiary-specific clinical information used for diagnosing, treating, or managing the condition, not just a note that a visit occurred. Telehealth encounters count if they meet all telehealth regulatory requirements.⁶

Missing documentation is the most common reason MassHealth defers a PA request.¹ Before you submit, confirm that your attachments speak to the diagnosis, prior treatment history, and clinical rationale. Vague notes or records from unrelated visits will not satisfy reviewers.

Submitting the Form

MassHealth requires electronic submission through the POSC. The POSC is a secure web portal where providers submit requests, attach documentation, and check status on prior submissions.⁷ When you submit online, the system validates provider ID, member ID, procedure code, and service dates before accepting the request, stamps it with a receipt date, and routes it to the appropriate consultant for review.⁴

Paper submission is reserved for providers with an approved electronic claims waiver on file. If you qualify, download the PA-1 as a PDF or Word document from mass.gov, complete it, attach your supporting records, and submit by:

Fax for nonpharmacy requests: (617) 988-8910.¹
Mail to the address printed on the PA-1 form itself.

Keep your fax confirmation page or mailing receipt. The review clock starts when MassHealth receives the request, not when you send it, so paper submissions effectively take longer to enter the system.

How Long a Decision Takes

As of January 2026, MassHealth decides complete standard PA requests within 7 calendar days of receipt. Expedited requests are decided within 72 hours.¹ Those timelines assume the initial submission is complete.

Expedited treatment is reserved for cases where the member’s clinical condition requires urgent attention and a standard-timeline delay could negatively affect health outcomes. A rescheduled procedure date, sudden availability of a clinical slot, or provider convenience does not qualify, and MassHealth will route a request that fails expedited criteria into the standard track.⁴ The underlying regulation, 130 CMR 450.303, also sets longer regulatory maximums that vary by service type (for example, 15 calendar days for DME and 21 for most other services), which operate as outer limits rather than the operational commitment.⁸

If the Request Is Deferred or Non-Compliant

When MassHealth cannot finish its review because information is missing, it sends a deferral notice to the provider and the member describing what is needed. You then have 14 calendar days to supply the missing documentation, either by attaching it to the existing request in the POSC or by mailing it in.¹ A deferral extends the overall review timeframe by up to 14 days from the date of the deferral.⁹

A submission that does not comply with the basic requirements at all (wrong form, wrong address, missing required fields) is handled differently. MassHealth notifies you what needs to be corrected and gives you 4 calendar days to fix it. If you miss that window, the decision clock pauses until the corrected submission arrives.⁸

Reading the Decision

After reviewing a complete request, MassHealth issues one of three decisions. An approval means the service meets clinical guidelines and can be delivered and billed. A modification means MassHealth approved a service that differs in quantity or nature from what was requested because it determined the modified version is appropriate for the member’s medical needs. A denial means the request did not meet coverage criteria and MassHealth will not reimburse the service.¹ Decision letters are mailed to both the provider and the member.

Prior authorization confirms medical necessity only. It does not guarantee payment. Other prerequisites still apply, including member eligibility on the date of service and resort to other available insurance.²

Appealing a Denial or Modification

Appeal rights belong to the member, not the provider. If MassHealth denies or modifies a PA request, the member may request a fair hearing through the Office of Medicaid’s Board of Hearings. The signed Fair Hearing Request Form must reach the Board within 60 calendar days from the date the member received the decision notice. Filings can be made by mail, fax, phone, email with password-encrypted attachments, or in person at 100 Hancock Street, 6th Floor, Quincy.¹⁰

Members who are already receiving a service that MassHealth proposes to terminate, suspend, or reduce can request that the service continue while the appeal is pending. To trigger this protection, the appeal must be received within 10 days of the date the member received the adverse notice. If the appeal is timely, benefits continue until the hearing decision is issued, though MassHealth can seek repayment if the hearing ultimately upholds the original denial.

1
MassHealth. Request Prior Authorization for Nonpharmacy Services
2
MassHealth. MassHealth Authorizations and Referrals
3
MassHealth Drug List. Introduction to Clinical Criteria
4
MassHealth. Prior Authorization for Non-Pharmaceutical Services – Frequently Asked Questions
5
Cornell Law Institute. 130 CMR 450.204 – Medical Necessity
6
Centers for Medicare & Medicaid Services. Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Order and Face-to-Face Encounter Requirements
7
MassHealth. Provider Online Service Center (POSC) Frequently Asked Questions
8
Cornell Law Institute. 130 CMR 450.303 – Prior Authorization
9
MassHealth. Prior Authorization Process Changes and Metrics
10
MassHealth. How to Appeal a MassHealth Decision