Pre-Claim Comparison Tool

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

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  COPPA: PMD COPPA: PRSS COPPA: LLP ADMC
States
  • Nationwide
  • Nationwide
  • California, Michigan, Pennsylvania, and Texas
  • Nationwide
HCPCS Codes
  • K0813-K0829, K0835-K0843, K0848-K0864
  • E0193, E0277, E0371, E0372, E0373
  • On 09/01/20: L5856, L5857, L5858, L5973, L5980, L5987
  • 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
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
  • 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
Resubmissions
  • 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
  • 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 PAR 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 PAR 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 PAR 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 Wed, 22 Jul 2020 17:21:23 +0000