Prior Authorization Lookup Tool

Determine which HCPCS codes require a Prior Authorization

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Prior Authorization

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
  • Nationwide
  • JA: MD, NJ, NY, PA
  • JB: IL, IN, KY, MI, OH
  • JC: FL, GA, LA, NC TN, TX
  • JD: AZ, CA, MO, WA
  • Nationwide
HCPCS Codes
  • Current: K0856 and K0861
  • Additional HCPCS as of 9/01/18: K0813-K0829, K0835-K0843, K0848-K0855
  • Current: K0800-K0802, K0812-K0829, K0835-K0843, K0848-K0855, K0890-K0891, K0898
  • PMD PA Demonstrations ends 8/31/18
  • Current Eligible PMDs: K0835-0843, K0848-K0855, K0862-K0864 K0890, K0891, K0013
  • As of 9/1/18: K0857-K0860, K0862-K0864, K0890, K0891, K0013
Requests Accepted From
  • A beneficiary or a DME supplier
  • A beneficiary residing in one of the participating states, a DME supplier, or a physician
  • A beneficiary or a DME supplier
Decisions
  • Initial Request: 10 business days
  • Subsequent Request: 20 business days
  • Expedited Request: 2 business days
  • Initial Request: 10 business days
  • Subsequent Request: 20 business days
  • Expedited Request: 2 business days
  • 30 calendar days
PA Decision Letter Recipients
  • Supplier
  • Beneficiary or physician, if specifically requested
  • Supplier, physician, and beneficiary
  • Supplier
Resubmissions
  • 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 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
  • CBA Supplier: Designated single payment amount
  • Non-CBA Supplier: A 25% reduction of Medicare payment after co-insurance and deductible applied

Voluntary program.
An affirmed ADMC decision means beneficiary meets medical necessity requirements for Medicare

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:
  • No GA modifier appended on claim (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)
Payment reduction is not eligible for appeal. Standard appeals process applies when:
  • Claim is billed with a non-affirmative PAR decision on file
  • Claim is denied after complex medical review and no prior authorization on file
ADMC is not eligible for appeal

 

Last Updated Jun 06, 2018