Pre-Claim Comparison Tool

This tool summarizes the key differences between the Pre-Claim programs: Prior Authorization (PA) and Advance Determination of Medicare Coverage (ADMC). Choose programs to compare.

 
  PA: PMD PA: PRSS PA: LLP PA: Orthoses ADMC
States
  • Nationwide
  • Nationwide
  • Nationwide
  • Nationwide prior to August 12, 2024, for L1832, L1833, L1851, L0648, and L0650
  • Nationwide August 12, 2024, for L0631, L0637, L0639, L0648, L0650, L1832, L1843, L1845, and L1951.
  • Nationwide
HCPCS Codes
  • K0800-K0802, K0806-K0808, K0813-K0829, K0835-K0843, K0848-K0864
  • E0193, E0277, E0371, E0372, E0373
  • L5856, L5857, L5858, L5973, L5980, L5987
  • Spinal Orthoses: L0631, L0637, L0639, L0648 and L0650
  • Knee Orthoses: L1832, L1851, L1843, and L1845
  • L1833 removed August 12, 2024
  • Ankle-Foot Orthoses: 1951
  • K0005, E1161, E1231-E1234, K0008, K0009, K0890, K0891, K0013
Requests Accepted From
  • A beneficiary or a DME supplier
  • A beneficiary or a DME supplier
  • A beneficiary or a DME supplier
  • A beneficiary or a DME supplier
  • A beneficiary or a DME supplier
Decisions
  • Initial Request: 10 business days
  • Subsequent Request: 10 business days
  • Expedited Request: 2 business days
  • Initial Request: 5 business days
  • Subsequent Request: 5 business days
  • Expedited Request: 2 business days
  • Initial Request: 10 business days
  • Subsequent Request: 10 business days
  • Expedited Request: 2 business days
  • Initial Request: 5 business days
  • Subsequent Request: 5 business days
  • Expedited Request: 2 business days
  • 30 calendar days
PA Decision Letter Recipients
  • Supplier
  • Beneficiary or physician, if specifically requested
  • Supplier
  • Beneficiary or physician, if specifically requested
  • Supplier
  • Beneficiary or Treating Practitioner if specifically requested
  • Supplier
  • Beneficiary or physician, if specifically requested
  • Supplier
Resubmissions
  • Unlimited
  • Unlimited
  • Unlimited
  • Unlimited
  • One resubmission may be requested in a six-month period
Payments
  • Any claim eligible for this program must be prior authorized before delivery of item or it will be denied as prior authorization is a condition of payment
  • Any claim eligible for this program must be prior authorized before delivery of item or it will be denied as prior authorization is a condition of payment
  • Any claim eligible for this program must be prior authorized before delivery of item or it will be denied as prior authorization is a condition of payment
  • Any claim eligible for this program must be prior authorized before delivery of item or it will be denied as prior authorization is a condition of payment
  • Voluntary program.
    An affirmed ADMC decision means beneficiary meets medical necessity requirements for Medicare
  • An affirmed ADMC is valid for six- month period from date of decision
Appeals Standard appeals process applies when claim is denied due to no PA submitted, in addition to:
  • No GA modifier appended (CO denial)
  • GA modifier is appended and Advance Beneficiary Notice of Noncoverage (ABN) deemed missing or invalid (CO denial)
  • GA modifier is appended and ABN deemed valid (PR denial)
 Standard appeals process applies when claim is denied due to no PA submitted, in addition to:
  • No GA modifier appended (CO denial)
  • GA modifier is appended and Advance Beneficiary Notice of Noncoverage (ABN) deemed missing or invalid (CO denial)
  • GA modifier is appended and ABN deemed valid (PR denial)
 Standard appeals process applies when claim is denied due to no PA submitted, in addition to:
  • No GA modifier appended (CO denial)
  • GA modifier is appended and Advance Beneficiary Notice of Noncoverage (ABN) deemed missing or invalid (CO denial)
  • GA modifier is appended and ABN deemed valid (PR denial)
 Standard appeals process applies when claim is denied due to no PA submitted, in addition to:
  • No GA modifier appended (CO denial)
  • GA modifier is appended and Advance Beneficiary Notice of Noncoverage (ABN) deemed missing or invalid (CO denial)
  • GA modifier is appended and ABN deemed valid (PR denial)
 ADMC is not eligible for appeal
Last Updated $dateUtil.getDate( $modifieddate , "MMM dd , yyyy" , $locale , $tzone )