Prior authorization request (PAR) submission requirements
Claim submission requirements
Prior authorization department contact information
Quick links and resources
CMS implemented a PA program for certain hospital OPD services, effective June 17, 2020, for dates of service (DOS) on or after July 1, 2020, nationwide. CMS believes prior authorization for certain hospital OPD services will ensure that Medicare beneficiaries continue to receive medically necessary care while protecting the Medicare Trust Fund from improper payments and keeping the medical necessity documentation requirements unchanged for providers.
As a condition of payment for DOS on or after July 1, 2020, a prior authorization request (PAR) is required for the following hospital OPD services:
Blepharoplasty, eyelid surgery, brow lift, and related services
Botulinum toxin injections
Panniculectomy, excision of excess skin and subcutaneous tissue (including lipectomy), and related services
Rhinoplasty and related services
CMS has added two new services to the hospital OPD PA program. As a condition of payment for DOS beginning on or after July 1, 2021, a PAR is required for these two additional hospital OPD services:
CMS provides a list of the specific healthcare common procedure coding system codes that are included in the OPD prior authorization program.
Hospital OPD when rendering certain OPD services for Medicare beneficiaries that bill Medicare Part A on a type of bill (TOB) 13X can receive prior authorization.
The hospital OPD (also known as the requestor) will be responsible to submit a prior authorization request (PAR) and all documentation for five groups of services and their related services before the services are provided to Medicare beneficiaries and before the provider can submit claims for payment under Medicare for these services. The five groups of hospital OPD services are blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation.
The program will apply to hospital OPD services effective June 17, 2020, for dates DOS on or after July 1, 2020.
The program applies to all jurisdictions nationwide.
CMS believes PA for certain hospital OPD services will ensure that Medicare beneficiaries continue to receive medically necessary care while protecting the Medicare Trust Fund from improper payments and keeping the medical necessity documentation requirements unchanged for providers.
It is designed to ensure all relevant coverage, coding, payment rules, and medical record(s) requirements are met before the service is rendered to the beneficiary and the claim is submitted for payment.
Submit the PAR and all documentation. A unique tracking number will be assigned with each PAR. An initial decision letter will be issued within 10 business days of receipt of initial request. Resubmission notifications will be issued within 10 business days of receipt of the resubmission request.
The hospital OPD, or provider on behalf of the hospital OPD, must submit the PAR to us before the service is provided to the beneficiary and before the claim is submitted for processing. The PAR must include all documentation necessary to show that the service meets applicable Medicare coverage, coding, and payment rules.
To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for services.
The requester can submit an expedited review of the PAR if it is determined that a delay could seriously jeopardize the beneficiary’s life, health, or ability to regain maximum function. However, if medical documentation does not support an expedited process, the request will be subject to the normal timeframe. We will make reasonable efforts to communicate a decision within 2 business days of receipt an accepted expedited request.
Prior authorization customer service phone number:
JL/JH Prior Authorization Requests (specify jurisdiction)
PO. Box 3702
Mechanicsburg, PA 17055
Priority mailing address:
Attention: JL/JH Prior Authorization Requests (specify jurisdiction)
2020 Technology Parkway
Mechanicsburg, PA 17050
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