Condition of Payment Prior Authorization Program ACT Questions and Answers - August 3, 2017

Overview

An acronym associated with this prior authorization program is UTN (Unique Tracking Number). It will be listed on the prior authorization decision letter. The UTN must be added to either Item 23 of the paper claim or the NTE and line-level segment loop 2300 or 2400 of the electronic claim.

CMS Medicare Learning Network (MLN) Matters (MM)9940 serves as notification of the prior authorization program for certain DMEPOS items. It also includes information about the establishment of the Master List of Certain DMEPOS Items meeting inclusion criteria and potentially subject to prior authorization. CMS will select HCPCS codes from the master list to be placed on the required prior authorization list and only those selected codes will be subject to prior authorization as a condition of payment. It is important to note that not all 135 items require a prior authorization.

HCPCS K0856 and K0861 are required to have a prior authorization as a condition of payment. See the K0856 - Group 3 Single Power Option and K0861 - Group 3 Multiple Power Option Power Wheelchairs webpage. This program initially began in March for four states and has been expanded nationally effective for dates of service and delivery on July 17, 2017.

Approved Advanced Determination of Medical Coverage (ADMC) requests that were submitted prior to July 17, 2017, will be considered for payment when delivered and billed.

A Condition of Payment Prior Authorization affirmation decision does not preclude another auditing entity from completing a post-payment review of the claim.

Excluded from this program are the following claim types: Veterans Affairs, Indian Health Services, Medicare Advantage and Part A and Part B Demonstrations. For those beneficiaries that are excluded from the K0856 and K0861 PA program, an ADMC should be offered, if applicable.

Coverage criteria, documentation requirements and appeal rights remain unchanged. An Additional Documentation Request (ADR) letter will be sent for claims submitted with a GA modifier so that the Advance Beneficiary Notice of Noncoverage (ABN) can be reviewed for validity.

While accessories are not subject to this prior authorization program, when the documentation supports the need for specific options or accessories that are needed to make that base unit operational and are needed to address a Medicare beneficiary's limitations, these options or accessories will be considered. The review of these options or accessories is in accordance with the Power Mobility Device Local Coverage Determination (LCD) in meeting the criteria for the selected power mobility device, therefore, one decision will be generated for the base item.

A prior authorization package can be submitted by the supplier or the beneficiary and should include the Prior Authorization Request (PAR) Coversheet K0856/K0861, face-to-face visit note, specialty evaluation performed by a Licensed, Certified Medical Professional (LCMP), Attestation Statement showing no financial relationship between supplier and the LCMP. Evidence of RESNA Assistive Technology (ATP) certification and involvement, 7-element order and the detailed product description.

See the Power Mobility Device (PMD) Prior Authorization Request (PAR) section of the Forms webpage for the Prior Authorization Request (PAR) Coversheet K0856/K0861 coversheet. Ensure that the coversheet is completed fully including whether this is an initial request or a resubmission by checking the applicable box. 

As a courtesy, Noridian will be sending decision letters to both the supplier and the beneficiary for supplier requested prior authorizations.

Initial requests will be processed and postmarked within ten business days. Subsequent requests may be submitted an unlimited number of times and will be processed and postmarked within 20 business days.

Questions and Answers

Q1. How can an accessory get approved for the base item?
A1. Only the base unit for HCPCS K0856 or K0861 will be reviewed. An accessory will be looked at when it is required to make the base unit functional. For example, the power tilt and recline is required for a K0861 to be approved. Therefore, the beneficiary must meet medical necessity criteria for power tilt and recline; however, the decision will include the base unit only.

Q2. If an ADMC that was submitted prior to July 17, 2017 requires additional information to be approved, can another ADMC be requested?
A2. An ADMC submitted prior to July 17, 2017 that was rejected must be resubmitted as a Condition of Payment Prior Authorization with the applicable coversheet for HCPCS K0856 and K0861.

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Last Updated Jun 19, 2019