1. (A) Notice of Approval. If the MassHealth agency approves a PA request for PCA services, the MassHealth agency will send written notice to the member, the PCM agency, and the fiscal intermediary regarding the frequency, duration, and intensity of care authorized, as well as the expiration date of the authorization.

2. (B) Notice of Denial or Modification and Right of Appeal.

   1. (1) If the MassHealth agency denies or modifies a prior authorization request for PCA services, the MassHealth agency will send written notice to the member, the PCM agency, and the fiscal intermediary. The notice will state the reason for the denial or modification and will inform the member of the right to appeal and of the appeal procedure.
   2. (2) If the MassHealth agency denies or modifies a prior authorization request for PCA services, or approves a prior authorization with a fewer number of hours from the immediately preceding prior authorization that ended within the past year of the present prior authorization approval date, a member may appeal by requesting a fair hearing. The request for a fair hearing must be made in writing to the MassHealth Board of Hearings in accordance with the timelines in 130 CMR 610.015(B): Time Limitation on the Right of Appeal. Requests for continuation of services during an appeal must be made in accordance with 130 CMR 610.036: Continuation of Benefits Pending Appeal. The MassHealth Board of Hearings will conduct the fair hearing in accordance with 130 CMR 610.000: MassHealth: Fair Hearing Rules.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4 Program Regulations

4-16

Provider Manual Series (130 CMR 422.000)

Transmittal Letter Date

Personal Care Attendant Services Manual

PCA-27 07/03/26