Background
General information
Coverage policies
Documentation requirements
Prior authorization request (PAR) submission requirements
Expedited requests
Claim submission requirements
Prior authorization department contact information
Educational events
Quick links and resources
CMS implemented a nationwide prior authorization program in July 2020 for certain hospital outpatient department (OPD) services, with additional services added in July 2021 and July 2023. 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.
Overall, as a condition of payment, a prior authorization request (PAR) is required for the hospital OPD services listed below.
Blepharoplasty, blepharoptosis repair, and brow ptosis repair
Botulinum toxin injections
Panniculectomy, excision of excess skin and subcutaneous tissue (including lipectomy), and related services
Rhinoplasty and related services
Vein ablation and related services
Cervical fusion with disc removal
Implanted spinal neurostimulators
Facet joint interventions
CMS provides a list of the specific healthcare common procedure coding system (HCPCS) codes that are included in the OPD prior authorization program.
Providers can use the Prior Authorization Code Lookup Tool (JH) (JL) to the verify if a code is subject to hospital OPD PA. The results given by the tool will advise if the code is subject to PA.
Note: Since CMS has mandated prior authorization for these particular hospital OPD services as a condition of payment, when a prior authorization request (PAR) is received and it has been determined that the related procedure has already been rendered, the PAR will be non-affirmed.
Question |
Answer |
Who |
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. |
What |
The hospital OPD (also known as the requestor) will be responsible to submit a prior authorization request (PAR) and all documentation for certain hospital outpatient 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. |
When |
Effective for DOS on or after July 1, 2020, the prior authorization applies to the following hospital OPD services: Blepharoplasty Botulinum toxin injections Panniculectomy Rhinoplasty Vein ablation Effective for DOS on or after July 1, 2021, the prior authorization applies to the following hospital OPD services: Cervical fusion with disc removal Implanted spinal neurostimulators Effective for DOS on or after July 1, 2023, the prior authorization applies to the following hospital OPD service: Facet joint intervention |
Where |
The program applies to all jurisdictions nationwide. |
Why |
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. |
How |
Submit the PAR and all documentation. A unique tracking number will be assigned with each PAR. An initial decision letter will be issued within 7 calendar days following the receipt of initial request. Resubmission notifications will be issued within 7 calendar days of receipt of the resubmission request. |
To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for services. For more information on coverage and documentation requirements, refer to the following articles.
For any service or item to be covered by Medicare, it must:
Be eligible for a defined Medicare benefit category.
Be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Meet all other applicable Medicare statutory and regulatory requirements.
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.
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:
855-340-5975 available Monday – Friday, 8 a.m. – 6 p.m. ET
Fax number:
833-200-9268
Mailing address:
Novitas Solutions
JL/JH Prior Authorization Requests (specify jurisdiction)
PO. Box 3702
Mechanicsburg, PA 17055
Priority mailing address:
Novitas Solutions
Attention: JL/JH Prior Authorization Requests (specify jurisdiction)
2020 Technology Parkway
Suite 100
Mechanicsburg, PA 17050
Please visit our educational event calendar (JH) (JL) for all available training opportunities and to register to participate in the webinars.
Prior Authorization Code Lookup Tool (
JH) (
JL)
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