Submitting a Prior Authorization Request (OPD) - JF Part B

Requesters are encouraged to include the following data elements in all Prior Authorization (PA) requests to avoid potential delays in processing. If the provider’s office submits the request, it is assumed the request is sent on behalf of the facility.

Note: Only one date of service per request.

Initial Submission Documentation

Beneficiary Information (as written on their Medicare card):

• Beneficiary Name
• Beneficiary MBI
• Beneficiary Date of Birth

Hospital OPD Information:

• Name of Facility
• Part A PTAN/CCN
• Facility National Provider Identifier (NPI)
• Facility Address

Physician/Practitioner Information:

• Physician/Practitioner’s Name
• Physician/Practitioner’s NPI
• Physician/Practitioner’s PTAN
• Physician/Practitioner’s Address

Requester Information:

• Requester Name
• Requester Phone Number
• Requester Address

Other Information:

• HCPCS Code(s)
• Diagnosis Code(s) (providers who submit using esMD must include a diagnosis code(s))
• Type of Bill
• Units of Service (providers who submit using esMD must include units of service)
• Indicate if the request is an initial or subsequent review
• Indicate if the request is expedited and the reason why

Resubmission(s) Documentation

In addition to the required PA request documentation in the Initial Submission section, the resubmission of the PA request should contain an exact match of the beneficiary’s first name, last name, and date of birth to the previous submission.

Implementation of Prior Authorization

MACs started accepting PA requests for the first initial services on June 17, 2020, for services provided beginning on or after July 1, 2020. The services being added for 2021 will begin accepting PA requests on June 17, 2021 with a date of service of or after July 1, 2021.

Sending a Prior Authorization Request

Requester have the following options for submitting PA request to Noridian:

• Mail
• Fax
• Electronic Submission of Medical Documentation (esMD), content type 8.5
• Noridian Medicare Portal (CMS-approved electronic portal)

Submissions through esMD available after July 6, 2020. For more information about esMD, visit the CMS Electronic Submission of Medical Documentation (esMD) webpage or contact Noridian.

Resources

• Prior Authorization for Certain Hospital Outpatient Department (OPD) Services (CMS)
• Federal Register