INSTRUCTIONS FOR COMPLETING THE PA-1 FORM (PLEASE PRINT OR TYPE.)
General Instructions
Complete Items 1 - 21 only. Enter all dates in mm/dd/yyyy format. Below are instructions for specic elds. All other elds are self-explanatory.
(A) Provider Information Section
Item 1 Provider’s Name, Address, and Tel. No. Enter the provider’s name, address, and phone number (including area code).
Item 2 Provider ID/Loc or NPI Enter the nine-digit requesting provider ID followed by the one-character location code.
If not available, enter the requesting provider’s 10-digit national provider identier.
Item 3 PA Assignment Select the type of PA you are requesting from the following list.
Basic Medical
Medical Pharmacy
DMR PCA Services
PCA Services
Pediatric PCA Services
PERS
Physician-Adult
Physician-Pediatric
Private Duty Nursing
Skilled Nursing
Vision
Other
Durable Medical Equipment
Absorbent Products
DME – Other
Enterals
Hearing Services
Mobility and Repairs
Orthotics and Prosthetics
Oxygen
Standers
Therapy Services
Occupational Therapy
Physical Therapy
Speech/Language Therapy
(B) Member Information Section
Item 4 Member’s Name, Address, and Tel. No. Enter the member’s name, address, and phone number (including area code).
Item 13 Explain why this service is medically
necessary
Diagnosis Code(s)
Place of Service
Description of Treatment
Enter a statement explaining why the proposed service is medically necessary. Include the primary diagnosis and
secondary diagnosis if there is one. Also include a description of the proposed treatment and prognosis. Refer to your
MassHealth provider manual for additional information about this eld.
Enter the ICD-9-CM diagnosis code(s) for the most relevant diagnoses for the procedure or item being requested.
Enter the location of service.
Enter a narrative of the proposed treatment.
(C) Services Requested Section
Item 14 Servicing Provider ID/Service Location
or NPI
Enter the nine-digit servicing provider ID followed by the one-character service location code. Write “same” if same as
requesting provider ID/Service Location. If not available, enter the provider’s 10-digit national provider identier.
Item 15 Service Code Enter the appropriate CPT or HCPCS code for each service requested. Refer to Subchapter 6 of the applicable MassHealth
provider manual to determine payable service codes. You must include a modier if the service code requires one.
Item 16 No. of Units Enter the number of times the service for which you are requesting prior authorization will be furnished. At least “1” must
be entered.
(D) Attachments and Signature
Item 17 Attachments Select the “Yes” box if additional information or supporting documentation is attached (refer to your provider manual);
otherwise select the “No” box. Be certain that the attached documentation clearly supports the medical necessity for the
services and/or equipment you are requesting (for example, X rays, admission notes, photographs, or explicit details).
Item 21 Provider Signature The form must be signed by the provider or the individual designated by the provider to certify that the information
entered on the form is correct. Signatures other than handwritten (that is, typewritten, or those by stamp or data
processing equipment) are acceptable.
(E) MassHealth Use Only
Items 22 – 38 Leave these items blank. MassHealth completes Items 22 – 38 when it reviews the request for prior authorization. Leave these elds blank.
See Subchapter 5 of your MassHealth provider manual for additional instructions for requesting prior authorization.
INSTRUCTIONS FOR MAILING REQUESTS FOR PRIOR AUTHORIZATION
Mail the Prior Authorization Request form, together with all necessary attachments, to:
MassHealth
ATTN: Customer Service Team
For Boston Region, use: P.O. Box 9154
For CCM, use: P.O. Box 9152
For Western Region, use: P.O. Box 9153
Hingham, MA 02043
