Required Prior Authorization Programs - JA DME

CMS issued a final rule that established a prior authorization (PA) process as a condition of payment for certain DMEPOS items that are frequently subject to unnecessary utilization.

The Master List contains the DMEPOS items identified as being frequently subject to unnecessary utilization; however, presence on this list does not automatically create a PA requirement for that item. CMS will implement a subset of items from the Master List (referred to as the "Required Prior Authorization List") and publish in the Federal Register with at least 60 days' notice before PA implementation of those items.

Access the below related information from this page.

• Pre-Claim Hotline
• Prior Authorization for Lower Limb Prosthetics
• Prior Authorization for Orthoses
• Prior Authorization for Osteogenesis Stimulators
• Prior Authorization for Power Mobility Devices
• Prior Authorization for Pressure Reducing Support Surfaces

Prior Authorization Education Opportunity

Noridian now offers additional education for Medicare Fee-For-Service Prior Authorization programs through our new Prior Authorization Collaborative Education (PACE) program. Each supplier will be provided with one-on-one education walking through the Prior Authorization processes, coverage criteria for the item of your choice that is listed on the prior authorization required list, and resources available. To sign up for one of these educational opportunities with a nurse please complete the DME Prior Authorization Collaborative Education Request Form and submit to dmepace@noridian.com.

Prior Authorization Timelines

Methods of Submission

• Noridian Medicare Portal (NMP)
  • A coversheet is not required for NMP submission
• Fax
• Mail
• Electronic Submission of Medical Documentation (esMD)

Affirmative and Non-Affirmative Decisions

After the PA submission goes through the medical review process, the supplier will receive a decision letter, whether affirmative or non-affirmative. These decision letters will be sent to the supplier by mail and can also be obtained from the Noridian Medicare Portal.

For more information on the Prior Authorization Process, please refer to the Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items Operational Guide (cms.gov)

• Submitters should note that the beneficiary and supplier addresses listed in the PAR will not be used by the DME MACs when sending review decision letters. The decision letters for suppliers will be made electronically available or mailed to the supplier address on file with the NPE and mailed to the beneficiary address on file with the Social Security Administration.
• When applicable, the prior authorization decision and corresponding claim information may remain with the beneficiary (i.e., the prior authorization decision identified via a Unique Tracking Number, or UTN, may transfer between suppliers). CMS assumes such transfers would be made in accordance with applicable privacy laws.

Although a Prior Authorization Affirmation Decision is provisional, the most obvious benefit of this program is that suppliers and beneficiaries will know whether the documentation for the item meets coverage criteria prior to delivery. It also provides the opportunity for the DME MAC to assess what additional information may be needed and provide feedback prior to an initial claim determination. Also, an affirmation decision does not preclude other entities from reviewing the claim decision.

Resources

• CMS Medicare Learning Network (MLN) Matters Special Edition (SE)18010 - Inclusion of Power Mobility Device Codes in the Prior Authorization Program for DMEPOS Items
• Federal Register Final Rule: Medicare Program; Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies