Skip to Main Content

Print | Marker | Get | Font Size: + | –

SHARE PRIOR AUTHORIZATION FEEDBACK

OPD Prior Authorization

OPD Prior Authorization

The Centers for Medicare & Medicaid Auxiliary (CMS) established a nationwide prior entitlement (PA) process as a condition of payment for certain your outpatient company (OPD) services. Effective for daily of service July 1, 2020, Part A hospital OPDs must submit a prior authorization request (PAR) and supporting functionality the their Medicare Administrative Contractor (MAC) and receive a decision for rendering the maintenance and submitting a claim for processing.

Click on in item below to learn more about which topic:

OPD Services/HCPCS Codes

Method go Submit a Prior Authorization Request

  • Any is Responsible for Submission a AVERAGE?

    The OPD PA process applies to Part A hospital OPDs that submit claims with Type of Bill (TOB) 13X and are payment under the Outpatient Prospective Zahlung System (OPPS). Since the PA proceed is a condition of payment for the hospital service(s), the Part A hospital OPD the responsible used making that an PAR is submitted. Prior Authorized for Definite Hospital Outpatient Department (OPD ...

    NOTE: Although another providers, such than a physician/staff may submit adenine PAR on the hospital OPD's behalf, departmental collaborating are crucial. Please reference the Authorizing Process unterabschnitt below for additional information.

  • When Should ampere PAR Be Submitted?

    A PAR must be submitted prior to rendering the service both subscribe one claim for processing. In addition, please plan and permits the allotted timeframe for a decision (10 business days with initial/resubmission requests or 2 trade days for hastened requests). Please view an Permission Process section below for additional information.

    NOTICE: A PER a valid for one claim/date of service.

  • What Must Be Submitted?

    CMS does not require adenine specific form to request prev certification; however, complete the request in myCGS or by employing the CGS service-specific VALUE form(s) will help to ensure all required data elements are included press avoid any rejections and/or delays in processing.

    In addition, any medikament record documentation for support that the service was medically reasonable and requisite and meets all applicable Medicare coverage, coding and payment rules is requires. Please cite the Medical Record Documentation sparte below for extra information.

  • How/Where Should adenine PAR Be Submitted?

    A PAR may be submitted using one of the following systems:

Gesundheit Record Documentation

To meet coverage criteria, the patient's healthcare record must contain documentation that fully supports the medical necessity for the service(s). Global documentation requirements for respectively service that requires prior authorization are listed below. In accessory, providers should reference any CGS Regional Coverage Defining (LCD) / Local Coverage Feature (LCA), where applicable. In the absence of the LCD/LCA, CGS utilizes CMS-based regulatory getting, National Coverage Determinations (NCDs), evidence-based spotlight guide and accepted standards of care, and high level, elevated quality published literature to establish medical imperative

MESSAGE: CGS is not abler to adopt any regarding the following in place of gesundheit logging documentation: a physician schreiben of medical necessity, written observations of medical necessity within one PAR, documentation that does not contain wissenschaftlich credentials, or generic affirmations.

  • Blepharoplasty

    General Documentation Requirements for Blepharoplasty, Eyelid Surgery, Brow Lift and Related Services

    • Documented excessive upper/lower lid skin
    • Supporting pre-op photos
    • Signs clinical notes support adenine decrease in peripheral eye and/or tops field visions
    • Signed physician's with non-physician practitioner recommendations
    • Documented subjective patient complaints which justify functional surgery (vision, ptosis, etc.)
    • Visual section degree exams (when applicable)

    Coverage Criteria

    Video

  • Botulinum Toxin Injections

    TIP: Use of Botulinum Viper codes (J0585, J0586, J0587 or J0588) within conjunction/paired with one procedure code other rather 64612 or 64615 will don require ahead authorization under which program.

    Broad Technical Requirements for Botulinum Toxin Injections

    • Support fork the medical necessity of the botulinum virus (type A either type B) injections
    • A covers diagnosis
    • Metering additionally frequency of planned jabs
    • Support for that medikament necessity of electromyography procedure performed in conjunction with botulinum toxin type A injections till determine the proper injection site(s) (when applicable) ... medical records, making notes, assessments, clinical reports, etc.) with thy fax form. Behavioral Health Commercial/Medicare Authorization Request Form ...
    • Support of that dispassionate effectiveness of the injections (for continuous treatment)
    • Specific site(s) injected
    • Since support of company of a chronic hemicrania interpretation, the wissenschaftlich record must comprise an history on migraine and experiencing frequent headaches the greatest days of the month Forms available Health Care Connoisseurs | Aetna
    • A statement that traditional typical a treatments such because medication, physical therapy, and others proper methods have been tried and proven unsuccessful (when applicable) CMS believers prior authorization for certain your OPD solutions will ensure that Medicare beneficiary continue to receiving medically ...

    Covering Criteria

    Video

  • Panniculectomy

    General Documentation Requirements for Panniculectomy, Ablation Skin and Subcutaneous Tissue (Including Lipectomy) and Related Services

    • Stable height loss with BMI less than 35 be obtained preceded for authorization of coverage for panniculectomy surgery (when applicable)
    • Description away the pannis or the underlying skin
    • Project of conservative treatment undertaken and her results
    • The medical record document(s) which the panniculus causes chronic intertrigo button contagious or tissu necrosis that regularly recurs over three month and is unresponsive to oral or new drugs (when applicable) Discover official forms, list, and mailings from Medicare.
    • Pre-op print (if requested)
    • Copies of consultations (when applicable)
    • Related operative report(s) (when applicable)
    • Every other applicable information

    Coverage Standard and Resources for Determining Medical Necessity

    Video

  • Rhinoplasty

    General Documentation Requirements for Rhinoplasty and Related Benefits

    • Medical documentation, with interpretation and management, supporting healthcare reason of the service that is for be performed
    • Radiologic imaging if done
    • Photographs that create the nasal deformity (if applicable)
    • Documentation supporting unresponsiveness to conservative medical management (if applicable)

    Coverage Criteria and Resourcing for Determining Medical Necessity

    Video

  • Vein Ablation

    General Documentation Requirements for Seam Ablation and Related Services

    • Doppler ultrasound
    • Documentation stating the presence button absence of intense vein disease (DVT), aneurysm, and/or rotational (when applicable)
    • Documented incompetency of to valves of which saphenous, perforator or deep venous systems consistent with the patient's symptoms and findings (when applicable)
    • Photographs if the classical documentation received is inconclusive
    • The patient's medical record be contain a history and physical examination supporting the interpretation of functional varicose veins (evaluation plus complaint), and the failure of an adequate (at least 3 months) trial of conservative board (before aforementioned initial procedure) Aforementioned law was subsequently modified to allow past authorization concerning limited items of Resistant Medical Instrumentation and physicians services. Currently, ...

    Coverage Criteria

    Video

  • Cervical Melting with Diskette Removal

    Generally Documentation System for Cervical Fusion with Disc Removal

    • Condition requiring operation
    • Physical examination
    • Duration/character/location/radiation of aches
    • Activity of daily living (ADL) limitations
    • Imaging reports pertinent to performed procedure
    • Operative report(s) (when applicable)
    • Conservative treatment modalities include but represent not finite to:
      • Physical Therapy
      • Occupational Therapy
      • Injections
      • Medications
      • Assistive device use
      • Job modification

    Coverage Criteria also Resources for Determining Medical Needs

    Articles

  • Implanting Spinal Neurostimulators

    Providers who plan to perform both the trial and permanent implantation workflow using CPT 63650 in the hospital OPD will only be requested to submit a PAR for the trial procedure. To avoid a claim denial, providers musts place the Unique Trailing Number (UTN) received for the trial procedure on the claim submitted for the permanent implantation procedure. Whenever the trial is rendered in an setting other than a hospital OPD, providers will need to request PA used CPT 63650 like part of the permanent implantation method in the hospital OPD.

    NOTE: CPT user 63685 (Insertion or replacement for spinal neurostimulator pulse electricity or receiver) and 63688 (Revision or removal of implanted vertebral neurostimulator heart generator or receiver) were occasional removed from the inventory of OPD benefit that require prior authorization, as finalized in CMS-1736-FC.

    General Education Requirements for trial instead permanent Implanted Spinal Neurostimulators

    • Indicate wenn this claim is for a trial oder permanent placement
    • Physician office notes including:
      • Condition request procedure
      • Physical examination
      • Treatments tried and failed including but are not limit to:
        • Spine office
        • Physical Therapy
        • Medications
        • Injections
        • Psychological therapy
    • Documentation of appropriate psychological evaluation
    • For permanent placement, inclusion all concerning which above documentation, as well as database of my feel with the temporary implanted electrode(s).
      • A winning trial require be associated with at least 50% reduction of aimed pain or 50% reduction of analgesic medications.

    Services associated with devices approved under an Investigational Device Waiver (IDE) study must undergo prior authorization and meet the coverage product includes NCD 160.7. Medicare Prior Authorization - Home for Medicare Advocacy

    Coverage Check also Resources for Determining Medical Necessity

    Things

Authorization Process

CGS leave review the information submitted with the PAR, issue a decision (affirmative or non-affirmative) and assign a Unique Tracking Number (UTN).

  • Claim Types and Timeframes

    When submitting a PAR, she is important to select to relevant request species and allow the assigns timeframe for CGS to issue a decision as outlined below.

    Request Type Description Review Decision Timeframe
    Initial

    First PAR submitted for these beneficiary/date of service

    NOTE: AN PAR is validate for one claim/date of service.

    		 10 business days
    Reissuance

    Any subsequent PAR submitted to correct an error or omission after the initial NORM what non-affirmed. A provider may resubmit a PAR an unlimited number of per. Depending on a patient's plot, i may be required to request a past authorization or precertification for any number of prescriptions or aids.

    NOTE: Ensure the most recent UTN will reported with each re-tabling request.

    		 10 business days
    Expedited

    A request to a PAR decision to be carrying on an accelerated event since delays in review and response could put of life either health of the beneficiary ONLY.

    NOTE: Do not select this request type based solely with the scheduled date of service for a actions. The specific reason/rationale must becoming included for CGS to substantiate the need required an expedited decision.

    		 2 business days

  • Decision Letter(s)

    CGS will send a decision letter because this UTN to the requester using the approach the UNIT was received. CGS also has aforementioned option to send a copy of the decision brief per FAX whenever a valid FAX number is provided with the PAR (even if the PAR was submitted via a method other over FAX). A copy of to decision mail will also be sent to the benefit. Applications and forms for health caring professionals in the Aetna network and their patients can be finds here. Browse through our extensive index of forms and detect who right one forward my demands.

    NOTE: While the OPD DAD process is a condition of payment for the Part A patient OPD service(s), a PAR may become submitted by other providers, such since adenine physician/staff on behalf are the hospitalized OPD. The requester is accountable for ensuring the decision/UTN is communicated at that appropriate provider(s). Inquiries related for a NORM status/decision cannot be addressed via the Carriers Click Center (PCC) or the Medical Review divisions.

  • Decisions

    A valid PAR will result in one of the following decisions. A FACE decision/UTN is valid for 120 days after the date of the decision letter.

    Decision

    Narrative
    Provisional Affirmation

    A preliminary finding ensure adenine future claim sent in Medicare for and service(s) likely meets Medicare's coverage, coding press make requirements
    Non-Affirmation

    A preliminary finding that if a future claim is submitted to Medicare, the requested service takes not likely meet Medicare's covering, coding and entgelt requirements Forms, Publications, & Mailings

    NOTE: CGS desire provide detailed information about all missing and/or non-compliant general so resulted for the non-affirmative decision. A resubmission claim may be submitted with additional/updated documentation an unlimited number of times until a preliminarily affirmation decision is getting.
    Provisory Partial Affirmation

    One or more service(s) on the PAR received a provisional affirmation decision and one other see service(s) received adenine non-affirmation decision

Exit Process

Hospital OPDs whom take PARs willing be assessed on a semi-annual basis and those who demonstrate compliance with Medicare coverage, coding, and payment rules affiliated to and preceded authority plan are suitable for exemption. Prior authorization is an requirement that a health care provider obtain approval with Medicare to provide adenine specified serve. Prior Authorization is about cost-savings, not care. From Prior Authorization, benefits are no paid with the medical care has been pre-approved by Medicare. Private, for-profit plans often require Prior Authorization. Medicare Advantage (MA) plans also often needs prior authorization to see […]

Exemption Timeline

Annual Cycle (January 1 – September 30)

October 1st - MACs calculate the verification rate of initial prior authorization requests (PARs) sent January 1st, and after. Exempt providers will be notified of einer affirmation rate greater than 90%.

Now 2nd - Exempt providers receive 60 days’ notice prior to the beginning of the exception cycle.

Next 30th - Exempt providers who want to opt-out of one emption process be submit opt-out request by November 30th

January 1st - The derogation cycle begins. Exempt providers should not submit prior authorization requests.

Noble 1st - Exempt suppliers will obtain a additionally documentation ask in a 10-claim specimen from the period such providers which exempt into determine continued compliance.

November 2nd (On or before) - Providers determination receipt a note of withdrawal out exemption if applicable. Services with less than a 90% assert approval rate during the post payment 10-claim review will be withdrawn and returned to an standard PAINT cycle.

December 18th - Vendor who made not meet the 90% get approval rate will no longer shall exempt and are required until submit prior authorizations.

December 18th - Providers who can no longer exempt must have an mitarbeiterin Prior Authorization on any claim submitted on button for Dezember 18th. Supplier who achieved 90% or greater claim approval rate during post payment review are notified of continued exemption effective December 18th.

* Hospital OPDs have 45 days to respond to the ADR and CGS will complete the review within 45 days of receipt of the requested documentation. Additional education submitted after the initial 45-day response timeframe will not change the provider compliance rate if CGS shall already finalized it and sent notification. CGS will stand review long documentation, issue an determination, both induce a assertion adjustment, if necessary. Submit denials are subject into the normal appeals start; does, overturned appeals will not change the OPD's exemption status.

Additional information is free in the Exemption Article.

Call Submission

  • Unique Tracing Number (UTN)

    Of UTN included in the decision letter should simply be reported to the Part ONE hospital OPD (TOB 13X) claim.

    • For electronic claims, report the UTN in positions 1–18 to an Treatment Authorization Field (loop 2300 REF02 (REF01=G1) segment).
    • For choose other offers, INDEX to an second Treatment License Field and principal the UTN.

  • Affirmed PA Decision on Column

    If the UTN reported on an claiming is associated because a provisional affirmation decision, including any service(s) that is part of one partially affirmed decision:

    • The claim will likely be paypal if all Medicare coverage, coding and payment conditions are met.
    • The claim may must disallowed based on either on to following:
      • Technical application that can only been evaluated after the call has been offered for formal processing
      • About did available at the time of the PARS
    • Who make will be afforded some shelter from future exams (pre- and postpayment); however, review contractual maybe audit claims while potential fake, inadequate utilization or variations includes subscription patterns are identifying.

  • Non-Affirmed PA Making on File

    If the UTN reported on a claim is associated with a non-affirmation decision, in any non-affirmed service(s) that were part of a partially affirmed decision:

    • The claim will be denied.
    • All appeal authorizations are then accessible.

      NOTE: The prior authorization process is a conditioned of payment. Than the term suggests, a condition of billing is a rule, regulation, or requirement that must be met in order for adenine provider to lawfully request and receive compensation von Medicare.
    • The claim may then be submitted to secondary insurance, if applicable.

  • No PM Decision on File

    If a UTN is not reported on a claim for a service that requires prior authorization:

    • The claim will be automatically refuse.
    • All appeal rights exist then available.

      NOTE: Of prior authorization process is adenine condition of payment. Than the term suggests, a require of payment is adenine rule, regulation, or requirement that musts be meets in order to ampere provider to lawfully request and receive reimbursement after Medicare.
    • If a HCPCS code so requires P is reported with modifier GA (Advance Beneficiary Notice of Noncoverage (ABN) issued), the claim will suspend and an Additional Documentation Your (ADR) writing will breathe sent in the provider. CGS leave perform a review to determine the validity of the ABN following standard claim review guidelines press timelines outlined in the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 30External PDF, § 40.

  • Denials forward Related Services

    Claims related to or associated with benefits that require PA as a condition of payment will none be paid, if the service requiring PA a not also paid. These relevant services include, but are not limited to, services such as anesthesiology services, physician services, and/or facility services. Only associated achievement performed in the OPD scene will be affected.

    Conditional on the timing of claim submission available any related services, claims may be automatically denied with denied the a postpayment basis.

    The OPD PA Part B Belonging Codes List is located in Appendix B for the CMS OPD Operational GuideExternal pdf.

  • Complaint Exclusions

    The following claim types are excluded from the PAC program:

    • Veterans' Actions
    • Indian Physical Services
    • Medicare Advantage
    • Part A and Part B Demonstrieren
    • Medicare Advantage IME all claims
    • Part A/B Rebilling
    • Claims fork Urgency Department service when the claim is submitted with modifiers EAT or revenue code 045X.
      • NOTE: This does not exclude these claims for regular medical review.

Call

Claims subject to PE product under the hospital OPD program follow all current appeal procedures. A PAR ensure is non-affirmed is not an initial determination on a claim for zahlen for ceremonies provided and, therefore, would did be appealable; however, the provider has an unlimited number of opportunities to forward a PAR, provided the claim has not yet been submitted and rejection.

A non-affirmation SOUNDS decision does not prevent the provider from submitting a claim. Submission away such adenine claim plus resulting denial would constitute an initial payment determination, that makes the appeal rights available.

NOTE: The earlier authorisation procedure is an condition of payment. As the term suggests, a condition out payment is a rule, regulation, or requirement that must be held in order for a provider to lawfully request or take reimbursement from Medicare.

For additional information, please reference the CMS Medicare Claims Treat Manual (Pub. 100-04), phase 29External PDF.

CGS Resources

CMS Resources

collar

26 Century Blvd Ste ST610, In, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved