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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 and the current PMD PA Demonstration. CMS may implement additional states and HCPCS codes for PA consideration in the future.

  Condition of Payment PA Program PMD PA Demonstration
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
HCPCS Codes K0856 and K0861 K0800-K0802, K0812-K0829, K0835-K0843, K0848-K0855, K0890-K0891, K0898
Requests Accepted From A beneficiary residing in one of the participating states or a DME supplier. A beneficiary residing in one of the participating states, a DME supplier, or a physician.
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
PA Decision Letter Recipients Beneficiary (if specifically requested) and supplier Supplier, physician and beneficiary
Resubmissions Unlimited Unlimited
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.
Appeals The standard appeals process applies when the claim is denied due to no PAR submitted, in addition to:
  • No GA modifier appended on the 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. The standard appeals process applies when:
  • The claim is billed with a non-affirmative PAR decision on file.
  • The claim is denied after complex medical review and no prior authorization on file.

 

Last Updated Dec 22, 2017