Introduction of the Prior Approval/Out-of-Plan Addendum Form
Posted on October 19, 2017
The new Prior Authorization/Out-of-Plan Addendum form must be used for members who have an HMO Health New England plan and are looking for services outside of their network. The submitting provider needs to submit the Massachusetts Standardized Prior Approval Request Form and the Out-of-Plan Addendum.
This request must explain why services are needed outside of the network. Appropriate clinical information (i.e., office notes) should also be included. If a provider fails to submit the required information, the request may be denied as not medically necessary. Click on the links below to access these forms.
These forms can also be found at healthnewengland.org/forms – click on Providers, then on Clinical Request Forms
