Article Detail - JA DME

Starting January 1, 2024, a temporary gap period is in effect for the Competitive Bidding Program (CBP) until CMS provides further notification. Claims with HCPCS codes L0648, L0650, L1833, and L1851 from non-contract physicians or practitioners that require prior authorization should not include the competitive bid modifiers KV, J4, or J5, as they will not be accepted. This is due to the absence of a CBP exception for non-contract physicians or practitioners. Treating practitioners can choose to undergo the standard prior authorization process within the regular timeframe, request an expedited review, or use the ST modifier to denote an acute or urgent need.

Claims with dates of service on or after January 1, 2024, with the ST modifier appended, to indicate acute/emergent need, will be subject to prepayment review. It is essential to highlight that this procedural change specifically affects non-contract competitive bid suppliers who are practitioners/physicians, physical therapists, and occupational therapists. For detailed information, please refer to the Timeline & Updates section of the Prior Authorization and Pre-Claim Review Initiatives webpage on the CMS website and the Noridian Medicare website for Competitive Bid information.