States |
- April 13, 2022: Power Operated Vehicles will require prior authorization
- Nationwide
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- Nationwide for dates of service on/after December 1, 2020
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- April 13, 2022: California, Florida, Illinois, New York
- July 12, 2022: Maryland, Pennsylvania, New Jersey, Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington
- October 10, 2022: Nationwide
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HCPCS Codes |
- K0813-K0829, K0835-K0843, K0848-K0864
- April 13, 2022: K0800, K0801, K0802, K0806, K0807, K0808
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- E0193, E0277, E0371, E0372, E0373
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- L5856, L5857, L5858, L5973, L5980, L5987
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- Spinal Orthoses: L0648 and L0650
- Knee Orthoses: L1832, L1833, L1851
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- K0005, E1161, E1231-E1234, K0008, K0009, K0890, K0891, K0013
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Requests Accepted From |
- A beneficiary or a DME supplier
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- A beneficiary or a DME supplier
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- A beneficiary or a DME supplier
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- A beneficiary or a DME supplier
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- A beneficiary or a DME supplier
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Decisions |
- Initial Request: 10 business days
- Subsequent Request: 10 business days
- Expedited Request: 2 business days
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- Initial Request: 5 business days
- Subsequent Request: 5 business days
- Expedited Request: 2 business days
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- Initial Request: 10 business days
- Subsequent Request: 10 business days
- Expedited Request: 2 business days
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- Initial Request: 5 business days
- Subsequent Request: 5 business days
- Expedited Request: 2 business days
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PA Decision Letter Recipients |
- Supplier
- Beneficiary or physician, if specifically requested
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- Supplier
- Beneficiary or physician, if specifically requested
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- Supplier
- Beneficiary or Treating Practitioner if specifically requested
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- Supplier
- Beneficiary or physician, if specifically requested
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Resubmissions |
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- One resubmission may be requested in a six-month period
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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
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- 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
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- 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
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- 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
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- 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
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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)
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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)
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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)
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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)
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ADMC is not eligible for appeal |