The following document was developed based on questions and answers posed during our webinars on the prior authorization (PA) program for certain hospital outpatient department (HOPD) services.
For details, links, and submission guidelines refer to Prior authorization (PA) program for certain hospital outpatient department (HOPD) services.
1. If the HOPD initiates the authorization process, can the performing physician/clinician submit clinical/medical documentation directly to Novitas separately?
No, each submission will be reviewed separately. The submission should be sent together, but the physician can submit the PA on behalf of the HOPD. The HOPD will be using the unique tracking number (UTN) assigned.
2. Can you please clarify the prior authorization request (PAR) process for Medicare secondary payer?
In situations where Medicare is the secondary payer, the requester submits the PAR with complete documentation as appropriate prior to providing the service.
3. The PAR must be submitted prior to the procedure, correct?
Yes, the PAR needs to be done prior to performing the procedure. Retroactive authorization is not applicable. Please remember that the PAR is valid for 120 days from the day the decision is made.
4. How do you obtain PA for physician billing and doing procedures at an HOPD?
The PAR only applies to the HOPD.
5. How do we fax photographs?
We recommend submitting the PAR through the Novitasphere portal, which allows for color images and sharper quality than a fax.
6. How do we go about signing up for electronic submission of medical documentation (esMD) to submit PA documentation online?
7. If a surgery date is changed or cancelled, can we request an extension of the 120 days?
No, a new PAR would be required.
8. Can you have overlapping PAR requests?
No, if your new date of service request would overlap the 120-day period already approved, then you would need to contact the customer contact center to expire the previous PAR.
9. Is the CMS certification number (CCN) the PTAN for the facility?
Yes, the CCN is the PTAN for the facility.
10. All the documentation for the PA originates with the ordering surgeon's evaluation and records. Why isn't the surgeon the one to request the PA with the requirement to include the facility where the surgery will take place? The facility will not encounter the patient until the date of surgery, so it does not seem logical to place the onus of documentation on the facility prior to ever seeing the patient.
The guidelines provided are a CMS directive. The provider (surgeon) can submit the PAR on behalf of the HOPD. The decision letter will be sent to the HOPD and the UTN provided is reported only on the UB-04 claim form not the CMS-1500 claim form.
11. Is there a plan to expand PA requirements to include other procedures/services in the future aside from those outlined in the webinar?
Novitas receives direction from CMS, please contact CMS.
12. As it relates to the prior authorization program, has anything changed for cosmetic surgeries?
If submitted without PA, an advanced beneficiary notice (ABN) will be needed. Otherwise, nothing has changed for medical necessity.
13. Does the PA program apply to ambulatory surgical centers (ASCs)?
The PA program does not apply to ASCs.
14. The patient’s surgery is scheduled in 7 days. Can I submit my PAR now?
A PAR should be submitted prior to scheduling the patient for the surgery. Providers should not schedule surgery until the affirmed decision letter and UTN are received for a PAR. Once a PAR is received, a decision will be made within ten business days. Do not submit an expedited PAR unless the beneficiary’s life or functional status is in jeopardy.
15. How far in advance are we able to submit a prior authorization request from the anticipated date of service?
A provisional affirmation is valid for 120 days from the date the decision was made. If the date of service is not within 120 days of the decision date, the provider will need to submit a new prior authorization request.
A best practice would be to submit a PAR at least two weeks prior to the expected date of the procedure.
Note: Since CMS has mandated prior authorization for certain hospital OPD services as a condition of payment, when a PAR is received and it has been determined that the related procedure has already been rendered, the PAR will be non-affirmed.
1. If the authorization is obtained by a physician's office, will the PA cover both hospital facility and physician or will the hospital have to get their own PA?
The physician's office can only submit a PAR on behalf of the HOPD. Therefore, the PA and UTN will be assigned to the HOPD. The physician's office does not need a UTN, but Medicare will not pay for the service(s) if the HOPD does not have an affirmed PA.
2. How do you follow up on PA after submitted via phone or fax or electronic?
To check the status of your request, please contact PA customer service at: 855-340-5975.
3. If the place of service (POS) changes from 19 (off-campus)/22 (on-campus) to 21 (inpatient) due to clinical condition and a notice of admission is sent, how will that impact my authorized claim?
If the service is changed from outpatient to inpatient hospital, the PA would not be necessary because the type of bill (TOB) for the hospital claim would change from TOB 13X to TOB 11X and the PA only applies to TOB 13X.
4. To be clear, does the hospital get the PA or does the surgeon's staff get the PA?
The PA applies to the hospital outpatient department. However, the surgeon may request the PA on behalf of the HOPD. However, the PA decision letter will be sent to the HOPD, the beneficiary, and the surgeon.
5. When a PAR is determined as non-affirmed, do we need to give 120 days until re-submitting another request or are we able to submit again as soon as we get the denial?
A resubmission PAR may be submitted as soon as you receive the non-affirmed decision.
6. When resubmitting a PAR can it be expedited due to the date of service for the procedure?
No, a request should only be expedited if it is determined that a delay could seriously jeopardize the beneficiary’s life, health, or ability to regain maximum function.
7. If the procedure did not meet the guidelines for approval, and if we get the information, can we submit for resubmission? What is the timeframe for resubmission?
Yes, you can do a PAR resubmission. You will receive a determination within 10 business days for a PAR resubmission. There is no limitation on how many PARs that can be submitted to obtain an affirmation.
8. If a PAR is denied, can a peer-to-peer review be done, or does a new PAR need to be submitted for the same service?
A peer-to-peer review would be considered on a case-by-case basis.
9. My PAR was dismissed because it said my photos were illegible. I sent the photos via fax. Why were the photos not acceptable?
The submission of photos via fax or mail is not ideal due to the lack of clarity. Faxed photos are only black and white and do not have sufficient detail required to support the PAR. We highly recommend using the Novitasphere portal for submitting photos. Novitasphere will provide the best quality and clarity for photos since they can be submitted in color.
10. What happens when a procedure has been scheduled but PA has not yet been received OR the corresponding authorization response is “non-affirmed”?
As explained in the CMS OPD operational guide
, if a service requires PA, then submitting a PAR is a condition of payment. Claims for HCPCS codes subject to required PA submitted without a PA determination and a corresponding UTN will be automatically denied. Recommendation: Do not schedule procedure(s) until affirmation has been received.
11. I submitted my PAR last week, but I have not received a response. Should I submit a new PAR?
Sending in a duplicate request for the same procedure(s) and date of service (DOS) is not recommended. Novitas has up to 10 business days to review the PAR and issue a decision. Submitting another PAR for the same procedure(s) and DOS is not necessary as this would be dismissed as a duplicate.
12. For a resubmission PAR, what needs to be submitted?
For a resubmission PAR be sure to include the following:
The initial PAR cover sheet
All documentation from the original submission
Any additional information/documentation
13. Does the UTN use the alpha O or the numeric 0?
UTN only uses the number 0 (zero) and never the letter O.
14. What are acceptable signatures?
15. What do I do if I see the signature and you do not?
Contact your electronic medical record (EMR) vendor as signatures must be on all documentation submitted for review.
1. How many days’ notice will I receive before I switch from Prior Authorization Request (PAR) submissions to an exemption cycle?
MACs will provide a 60-day notice prior to any transition period, continuation, or withdrawal from exemption.
2. I received a letter stating that I am starting exemption. What do I do now?
PARs should not be submitted and will be rejected during the exemption cycle. Claims submitted while on exemption will not require a unique tracking number (UTN). Please follow the instructions in the exemption notification letter.
3. I received a letter stating I am now withdrawn from exemption. What do I do now?
Providers will resume submitting PARs beginning December 18 for dates of service on or after January 1. PARs will be required starting January 1. Your PAR affirmation rate will be monitored for the next exemption cycle.
4. Why are my PARs being rejected while on exemption?
PARs are not required while a provider is on exemption, therefore any PAR submitted will be returned with a rejection decision. PARs should not be submitted for the purpose of obtaining a rejection letter for medical record keeping.
5. How do I bill PA claims without a UTN during the exemption period?
PA services that were performed during the exemption period should follow the same billing practices used prior to the start of the exemption period. Applying previously used UTNs or invalid UTNs may delay processing of your claim.
6. Towards the end of the exemption cycle the MAC conducts a ten-claim post payment review. How are the claims selected?
The ten-claim sample is based on claims subject to the OPD PA program submitted during the exemption period. This means that the claims selected will be from the timeframe in which you were exempt.
7. Does the exemption process exempt providers from all OPD PA services?
Yes. If you receive a notice of exemption, it applies to all services under the OPD PA program. If CMS adds new procedures to the Prior Authorization Program during the Exemption Cycle, they will be included in the exemption process for the provider.
8. If an exempt provider submits a PAR on 12/21 but it is non-affirmed, and the provider then becomes exempt on 01/01, does the provider need to resubmit the PAR? Will that resubmission reject if it is past the exempt start date?
You do not need to resubmit if the procedure is performed after the start of the exemption period. If you do resubmit the PAR on or after 01/01 it would be rejected.
9. If I am an exempt provider, but during ADR review, it is determined that I no longer meet the requirements to remain exempt, when do I need to resume submitting PARs and begin adding a UTN to my claims?
MACs will start accepting PARs from providers who are withdrawn from exemption on December 18. Claims with dates of service on or after January 1 require a UTN.
10. What does it mean to opt out of exemption?
CMS has established a rule that allows providers to remain in the standard cycle and continue to submit PARs. Providers will receive a notice of exemption if they achieved a greater than 90% PAR affirmation rate. An opt-out form will be included with the exemption notification letter. The form must be submitted to the MAC by November 30. Late requests will be rejected.
11. What are ADRs?
Additional documentation requests: ADRs are issued based on a specific claim submitted to your MAC. The ADR will specify the beneficiary and date of service and include a list of suggested documentation for a particular service to submit to your MAC that would support payment of your claim.
12. How many claims will be selected for ADR review?
Your MAC will randomly select ten post-payment claims for the ADR review.
13. What is the ADR timeline?
An ADR for exempt providers will be sent on August 1. The provider has 45 days to submit the documentation and the MAC has 45 days to review the documentation and make a determination. Notification of withdrawal will be sent out no later than November 2.
Exempt providers will receive an ADR for a random ten claim post-pay review.
Providers have 45 days to submit documentation.
MACs have 45 days to review.
MACs will send notification letters for either continued exemption or withdrawal from exemption.
Providers must achieve a greater than 90% claim approval rate with post pay claim review to continue with exemption.
Providers who received a notification of withdrawal from exemption may submit PARs.
Additional information on the exemption process is available in the CMS OPD operational guide and our article, Hospital outpatient department (OPD) prior authorization exemption process.
1. Is Novitasphere available now?
Novitasphere is available for PAR submissions as of June 17, 2020.
2. Regarding the submission of the PAR through Novitasphere, is there a step-by-step guide on submitting the authorization?
3. Will Novitasphere provide status on the PA or must you call for status?
Once the request is successfully submitted via Novitasphere, a confirmation notification will be generated. Once a determination is made for the PA, a decision notification is sent back through Novitasphere to the mailbox of the account the PAR was submitted from. You may call PA customer service at 855-340-5975 to check the status of your request(s). Note: the PTAN, NPI, and last 5 digits of the Tax ID of the hospital OPD must be provided for authentication when you call.
4. Will decision letters be available in Novitasphere?
Yes, decision letters will be available in Novitasphere.
5. If we submit the PAR via the Novitasphere portal will the response still be by fax?
Yes, a response will be sent via the Novitasphere portal and to the fax number if provided on the coversheet.
1. I do Part B billing only, so if the Part B claim is submitted without a UTN, will that be denied, or would this only apply to Part A claims?
Currently, only the Part A claim requires the addition of the UTN. The UTN will not apply to the Part B claim, but if listed on the Part B claim, the claim will reject.
2. It is understood that if the PAR for the hospital was non-affirmed and the hospital submits a claim, the claim will be denied. Will this denial only apply to the hospital’s claim or will it apply to the surgeon’s claim as well?
We would not expect to receive the claim from the surgeon if the HOPD PAR was non-affirmed.
CMS clarified that claims related to or associated with services that require prior authorization as a condition of payment will not be paid, if the service requiring prior authorization is also not paid. These related services include, but are not limited to, anesthesiology services, physician services, and/or facility services. Only associated services performed in the HOPD setting will be affected.
Depending on the timing of claim submission for any related services, claims may be automatically denied or denied on a post payment basis.
3. With non-affirmation and claim submission, appeal rights are afforded; can the appeal be overturned by making a case for medical necessity?
Yes, appeals are subject to medical necessity.
4. What is the field locator on the UB-04 and the loop/location for electronic billing where the UTN for the PA should be reported on a claim?
For the UB-04, submit the UTN in form locator 63:
Report the UTN on the same line (A, B, C) that Medicare is shown in form locator 50 (payer line A, B, C)
UTN should begin in position 1 of form locator 63
electronic claims, submit the UTN in the 2300 - Service Line loop in the prior authorization reference (REF) segment:
REF01 = "G1" qualifier and REF02 = UTN
This meets the requirements of the ASC X12 837 technical report 3 (TR3)
5. Can you provide more clarification on claim submission deadlines?
The UTN is valid for 120 days from date of the decision letter. The service must be performed within the 120-day range specified in the decision letter. If the DOS is outside the 120 days, then the UTN is no longer valid and a new PAR is required. The 120 days for the UTN does not impact claim timely filing. Claims must be filed within one year of the DOS.
6. If the PAR is denied, and the patient signs the ABN, will everything be paid except for the procedure itself and leave the patient responsible for the cost of the procedure itself?
If not listed on the ABN, the beneficiary would not be liable.
7. How do you bill on a 1500 form? How do you submit for a physician bill?
Continue to bill as normal, until further CMS clarification is given. It is expected that if the HOPD receives a non-affirmation, they would notify the physician so that the physician can make an informed decision regarding the POS they plan to perform the service. CMS recently confirmed that any claim associated with or related to a service that requires PA for which a claim denial is issued, would also be denied. This includes, but is not limited to, anesthesiology services, physician services, and/or facility services.
8. Does the UTN from the decision letter need to be documented in the chart note and the claim or just the claim?
The UTN only needs to be documented on the claim.
9. If a PAR is not obtained, is the provider able to appeal the denied claim?
1. Are private physicians required to submit a PA for Botox in their office?
No, a PA is required by the HOPD when the service is going to be provided in the HOPD. The PA applies to the 13X TOB.
2. Will we need to submit a revised authorization post procedure if we go over the number of units for Botox?
If the claim is submitted with more units than specified on the PAR, then the claim will be denied.
3. Can you confirm that Botox J-codes only need prior authorization if they are used in conjunction with 64612 or 64615?
Yes, prior authorization is only for J-codes submitted with 64612 or 64615.
4. What will happen to my claim if it is only billed with an administrative code or the drug code?
Claims will now return to provider (RTP) that are billed with the drug code without an administration code or if claims are billed with the administration codes without the drug code.
5. Is there a list of diagnosis codes covered by Medicare for Botox?
The PA program is currently based only on procedure codes and not the diagnosis codes.
6. Botox can be injected per label every 12 weeks and a PA is good for 120 days. Can a provider bill for two separate dates of service under one PAR/UTN request?
No, only one date of service may be authorized per PAR.
7. Would it be your recommendation that all botulinum toxin services be submitted for PAR regardless of the indication in that there is not a formal medical necessity policy?
8. If Botox being given in the provider's office, is billed using provider-based billing (performed in the office, but billed as an outpatient department of the hospital), it would require a PA, correct?
The PA is required for the HOPD billing a TOB 13X. For provider-based billing, the provider/physician will bill the claim on the 1500 claim form with the POS 19 (off-campus) or 22 (on-campus) while the HOPD will bill the claim on the UB-04 with a TOB 13X.
9. Do we need approval for the 64644 and 64616 with the Botox J0585/J0588?
10. If a Botox injection will be given in the operating room for an outpatient surgical procedure, will this require a PAR?
The PAR is required if the service is performed in a HOPD billing a TOB 13X.
1. Does Septoplasty (code 30520) need a PA when done alone, or does it require a PA when done in conjunction with rhinoplasty?
1. Your panniculectomy local coverage determination (LCD) states 18 months after bariatric surgery. No other Medicare administrative contractor requires that long a timeframe. What was the basis of that timeframe? Is it absolute? What if weight stable for 6 months and it is 12 months after surgery?
1. Are PAR requests required for radio frequency ablations unrelated to a diagnosis of deep vein thrombosis?
2. How many units should be requested for bilateral services, 1 or 2?
Every code is specific to one; however, there are modifiers that impact the claim. Please refer to the Current Procedural Terminology manual.
1. Are photographs required for review of Blepharoplasty and related services?
2. Does an interpretation of the visual field testing need to be submitted for review?
3. How many units should be requested for bilateral services, 1 or 2?
Every code is specific to one; however, there are modifiers that impact the claim. Please refer to the CPT manual.
1. When is conservative treatment required?
Conservative treatment is tailored to the beneficiary's care plan. Conservative treatment may consist of, but is not limited to injections, medications, physical therapy, or occupation therapy, assistive device use. Each request is reviewed individually to determine if medical necessity is met.
2. When does a Cervical Fusion meet expedited criteria?
A request should only be expedited if it is determined that a delay could seriously jeopardize the beneficiary’s life, health, or ability to regain maximum function.
1. When should a PAR be submitted for a permanent Implanted Spinal Neurostimulator?
Providers who plan to perform both the trial and permanent implantation procedures using CPT 63650 in the hospital OPD will only be required to submit a PAR for the trial procedure. However, if the permanent implant occurs after the 120-day expiration date of the trial UTN, a new PAR will need to be submitted for the permanent implant.
2. If the trial implant is being rendered in an Ambulatory Surgical Center (ASC) or provider office, is a PAR required?
No, PAR is only for trials rendered in the hospital OPD setting.
3. If the trial is rendered in a setting other than hospital OPD (ASC or provider office), is a PAR needed for the permanent implant?
When the trial is rendered in a setting other than hospital OPD, providers will need to request PA for CPT 63650 as part of the permanent implantation procedure in the hospital OPD.
4. What is considered documentation of appropriate psychological evaluation?
1. How does COVID-19 testing affect the PAR?
When scheduling procedures and submitting PARs, be aware that timeframes have not accounted for COVID-19 testing required prior to a procedure. COVID-19 testing can take weeks and may cause delays. A PA decision is made within 10 business days of the receipt of a PAR and the service must be performed within 120 days of the UTN and date range of the authorization specified in the decision letter.
Questions regarding topics not currently defined in CMS or Novitas published resources related to the PA program for certain hospital OPD services can be sent to OPDPA@cms.hhs.gov.
If you have questions regarding Medicare processing, please contact PA customer service at: 855-340-5975.