We have been processing prior authorization requests (PARs) since the implementation of the program and have found errors and omissions in these requests. These errors and omissions can result in delays or dismissals of the PAR.
The following are tips and reminders that will assist you in avoiding a delay or dismissal of a PAR.
PARs are required for certain OPD services billed on a type of bill 13X provided at a hospital OPD that are on the CMS list of procedures requiring PA. This means if the physician's place of service (POS) is 19 or 22, a PAR will be required for the hospital OPD. A PAR is not required for ambulatory surgical centers (ASCs) or services performed in the physician's office (POS 11).
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 general documentation requirements and medical record checklists.
PARs have been dismissed as non-affirmed for incomplete or invalid information on the PAR cover sheet. To prevent dismissals or processing delays of the PAR, we encourage you to use our PAR cover sheet. Instructions on completing the PAR are available.
Include the facility and provider CMS certification numbers (CCNs) and National Provider Identifiers (NPIs) in the proper fields.
Include the correct Medicare Beneficiary Identifier.
Include only applicable CPT or HCPCS codes from the CMS
list of procedures requiring PA.
Do not include procedures codes for services that do not require PA.
Addresses are needed.
Ensure the PAR is legible.
Cover sheet should be submitted along with appropriate documentation.
Use the correct PAR cover sheet:
Ensure the PAR is sent to the correct MAC.
PAR resubmission must include:
The initial PAR cover sheet.
All documentation from the original submission.
Any additional information/documentation.
Unique tracking number (UTN) associated with the previous submission.
PARs have been dismissed due to photos being submitted to support the PAR as illegible or missing.
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.
Submission of photos via fax or mail is not ideal due to the lack of clarity.
Faxed photos are only black and white - do not have sufficient detail required to support the PAR.
The following service specific issues have been identified on submitted PARs.
Records have been submitted with illegible writing. The documentation needs to be legible.
Visual field testing submitted without a full dictation of what was determined from the visual fields. An interpretation in writing of what the tests show to support medical necessity is needed.
Photos submitted were illegible or not included in the PAR. Follow the guidance above when including photos.
PA is only required when one of the required botulinum toxin codes (J0585, J0586, J0587, or J0588) is used in conjunction with the one of the required CPT injection codes, 64612 or 64615. To avoid a dismissal or delay in the PAR, ensure the following is reported:
The number of units of each code being requested separately (do not combine units).
Each J-code must correlate with the amounts specified by the CPT code.
The amount of the medication and injection must be specified in the documentation.
Documentation submitted does not support the medical necessity specifically related to services performed 18 months after bariatric surgery and with stable weights for 6 months.
Photos submitted were illegible or not included in the PAR. Follow the guidance above when including photos.
If the beneficiary needs deviated septum repair, in order to perform another service, this needs to be specified in the documentation.
Photos submitted were illegible or not included in the PAR. Follow the guidance above when including photos.
Documentation must include a plan of care, for a 90-day episode of care, that supports the evaluation of the patient including a history, physical examination, CEAP clinical classification, VCSS and a formal venous duplex scan.
Requesting the appropriate units of 63650 (for example: 2 units for two leads).
Psychological evaluation must be performed by a mental health professional and signed with the appropriate credentials.
Documentation must support this is a late if not last resort option for pain management.
Documentation of conservative therapy if applicable.
Request the appropriate CPT code and units for (22551, 22552) on the fax sheet if planning on performing a multi-level fusion to avoid resubmitting another request.
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