What is prior authorization?
Prior authorization (PA)—also called preauthorization—means the health plan must approve certain care before it will cover it. Doctors or hospitals often submit PA for you, but you still have rights if PA is denied.
A PA denial is different from a bill denial after care already happened. With PA, the fight is usually about whether the plan will allow the treatment at all.
Overview for any state: Prior authorizations. This page is Massachusetts-only.
Confirm plan type: Massachusetts: Start Here.
Massachusetts PA rules
Massachusetts regulates utilization review and prior authorization in M.G.L. c. 176O, especially § 12 (utilization review) and § 25 (uniform PA forms).
Initial utilization review (§ 12)
- Initial determination on a proposed admission, procedure, or service often within 2 working days after the carrier obtains all necessary information
- Telephone notice to the provider within 24 hours for approvals and denials; written confirmation to insured and provider shortly after
- Adverse determinations made by a licensed clinician in the appropriate specialty (not solely by non-clinical staff)
- Opportunity for clinical peer reconsideration within 1 working day before formal grievance
- Concurrent review determinations often within 1 working day; services continue until notice of denial
Uniform PA forms (§ 25)
- Carriers must use Division of Insurance–designated PA forms for covered service types (electronic portals allowed if consistent with the paper form)
- If the payer fails to use or accept the required form, or fails to respond within 2 business days after receiving a completed request, the PA request is deemed granted
Notice requirements
Written adverse determination notices must include clinical justification, the information relied on, alternatives if offered, and applicable guidelines (§ 12(d)).
Where to look up PA rules
Carriers must publish utilization review criteria on their websites. Use the links on Massachusetts: prior auth & internal appeals links or call the number on the member ID card.
Marketplace plans are sold through Massachusetts Health Connector; major carriers include Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim, Tufts Health Plan, UnitedHealthcare, WellSense, Fallon Health, and others.
MassHealth
MassHealth and its managed care contractors follow Medicaid authorization and appeal rules. PA denials may be appealed through the MCO and fair hearing process—see How to appeal a MassHealth decision and Massachusetts internal appeals.
If PA is denied
A PA denial is an adverse determination. You may pursue clinical peer reconsideration, then the carrier's formal grievance process under § 13.
Next: Massachusetts internal appeals → Massachusetts external review (OPP).
Urgent care
Carriers must maintain expedited grievance procedures for urgently needed services (§ 13(b)), including resolution before hospital discharge and within 72 hours for many urgent claims. You may request simultaneous expedited internal and external review (§ 13(d), § 14(b)).