Required Prior Authorization Suspended for the Duration of the COVID-19 Pandemic - JA DME

Effective on or after March 01, 2020, the Centers for Medicare & Medicaid Services (CMS) and the DME MACs are suspending the requirements to prior authorize certain power mobility devices (PMDs) and pressure reducing support surfaces (PRSS). Also, the implementation of Prior Authorization (PA) of Lower Limb Prostheses scheduled to begin on May 04, 2020 is delayed. This suspension of PA will last for the duration of the COVID-19 Public Health Emergency (PHE).

The DME MACs will continue to accept and review voluntary PA requests for the affected HCPCS codes on the Required Prior Authorization List; however, claims associated with a non-affirmation decision or claims submitted without requesting prior authorization that would normally cause a payment denial will be processed for payment for the duration of the COVID-19 PHE. Claims bypassing PA may be selected for post-payment review after the PHE has ended.   

Claim Filing Instructions

Suppliers must continue to use the appropriate modifiers for all HCPCS codes on the Required Prior Authorization List. For the duration of the COVID-19 PHE, suppliers are to apply the CR modifier (CATASTROPHE/DISASTER RELATED) to the claim line(s) for the HCPCS code(s) billed. Additionally, suppliers are instructed to enter "COVID-19" in the NTE 2400 (line note) or NTE 2300 (claim note) segments of the American National Standard Institute (ANSI X12) format or field 498-PP of the National Council for Prescription Drug Program (NCPDP) format. These abbreviations may also be used in Item 19 of the CMS-1500 claim form. These instructions also apply to all subsequent rental months' claims in order to ensure continued payment throughout the rental series.

Reopenings

For claims denied due to the COVID-19 PHE that are associated with PA submissions on or after March 01, 2020 and prior to this notice, suppliers may request a reopening of their claim by contacting their MAC.

Further communication and instruction will be provided once a date for resuming PA is established.

Publication History