The MassHealth agency, or its designee, determines complex care authorizations for members who meet the clinical eligibility criteria in accordance with 130 CMR 422.414(A).

1. (A) Complex Care Authorization Clinical Eligibility. MassHealth members may qualify for a prior authorization for PCA complex care if their evaluation for PCA services demonstrates clinical need for either

   1. (1) digital stimulation related to bowel regimen; or
   2. (2) enteral feeding tube.
2. (B) Prior Authorization Requirement. The complex care authorization is determined in accordance with 130 CMR 422.416. The MassHealth agency may, at its discretion, request additional information to evaluate a member’s request for a complex care authorization including, but not limited to, documentation supporting the medical need for one or more activities identified at 130 CMR 422.414(A).
3. (C) Complex Care Differential Payment. Complex care differential payments are made in accordance with 130 CMR 422.418(C).

(130 CMR 422.415 Reserved)

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4 Program Regulations

4-13

Provider Manual Series (130 CMR 422.000)

Transmittal Letter Date

Personal Care Attendant Services Manual

PCA-27 07/03/26