Prior Authorization Lookup Tool
Determine which HCPCS codes require a Prior Authorization
Enter HCPCS Code:
Required Programs - CMS has implemented prior authorization (PA) as a condition of payment for specific HCPCS codes.
Power Mobility Device (PMD) PA Demonstration - The PMD PA Demonstration is for designated PMDs for Medicare beneficiaries residing in eligible states, and will remain effective until August 31, 2018.
Condition of Payment PA Program vs. PMD PA Demonstration Comparison
The following table summarizes the key differences between the Condition of Payment PA Program, the PMD PA Demonstration and Advance Determination of Medicare Coverage (ADMC).
|Condition of Payment PA Program||PMD PA Demonstration||ADMC|
|States|| || || |
|HCPCS Codes|| || || |
|Requests Accepted From|| || || |
|Decisions|| || || |
|PA Decision Letter Recipients|| || || |
|Resubmissions|| || || |
|Payments||Any claim eligible for this program must be prior authorized before delivery of the item or it will be denied as prior authorization is a condition of payment|| Claims billed that are eligible for the demonstration will undergo complex medical review if prior authorization is not utilized || |
An affirmed ADMC is valid for a six- month period from date of decision
|Appeals|| Standard appeals process applies when claim is denied due to no PAR submitted, in addition to: || Payment reduction is not eligible for appeal. Standard appeals process applies when: ||ADMC is not eligible for appeal|
Last Updated Jun 06, 2018