FAQ: Prior Authorization
1. How long should I wait for a response from the Prior Authorization/Program Exception (1150 Waiver) area?
The patient and the prescribing/rendering provider should receive a written response to a request for Prior Authorization/Program Exception (for a patient under 21 years of age) within 21 days. Regulation 1101.67 (relating to prior authorization) which requires a decision on requests for prior authorization within 21 days, does not apply to requests for program exception for a patient 21 years of age or older. If the patient and/or prescribing/rendering provider does not receive a written response, the patient or his/her representative may call the PA Recipient Hotline to request information on the authorization. The provider may call the provider inquiry unit to request information on the authorization or to check the status of a request. In either scenario, the number to call is 1-800-537-8862.
2. What is an MA 97 form? What is an ADA 2012 form? How can I obtain a PA request form? How do I complete it? Where do I send the completed form?
The MA 97 - Outpatient Services Authorization Request form is used to request a medical service/supply that requires prior authorization/program exception. The MA 97 Prior Authorization Request Form can be printed from the Medical Assistance Forms web page or ordered off of the MA 300X - Medical Assistance Provider Order Form (PDF download). Instructions for completing the MA 97 request form, as well as where to mail the completed form is printed on the form.
The ADA 2012 form is used to request dental services that require prior authorization. The ADA 2012 form can be ordered from several sources, including the American Dental Association.
3. Is prior authorization required on a service provided when the hospital is an out-of-state facility? How does the out-of-state facility bill?
Prior authorization is not required by an out-of-state facility when emergency services are provided in accordance with Regulation 1163.65. Prior authorization is required for "non-emergent/urgent out of state services" as per Place of Service Review Procedures on MA Bulletin 01-06-01; 02-06-01; 14-06-01; 31-06-01; 27-06-02. For questions related to services provided and billing, call the provider inquiry unit at 1-800-537-8862.
4. Is prior authorization required for MRIs, CT Scans, and other advanced radiologic imaging services?
The following advanced radiologic imaging services require prior authorization review by calling - 1-800-537-8862: CT Scans, MRA Scans, MRI Scans, MRS Scans, Nuclear Medicine Cardiology Scans, PET Scans, and SPECT Scans. Please refer to MA Bulletin 01-14-42 for more information.