Required Prior Authorization Programs

CMS issued a final rule that established a prior authorization (PA) process as a condition of payment for certain DMEPOS items that are frequently subject to unnecessary utilization.

The Master List contains the DMEPOS items identified as being frequently subject to unnecessary utilization; however, presence on this list does not automatically create a PA requirement for that item. CMS will implement a subset of items from the Master List (referred to as the "Required Prior Authorization List") and publish in the Federal Register with at least 60 days' notice before PA implementation of those items.

Access the below related information from this page.

Prior Authorization Education Opportunity

Noridian now offers additional education for Medicare Fee-For-Service Prior Authorization programs through our new Prior Authorization Collaborative Education (PACE) program. Each supplier will be provided with one-on-one education walking through the Prior Authorization processes, coverage criteria for the item of your choice that is listed on the prior authorization required list, and resources available. To sign up for one of these educational opportunities with a nurse please complete the DME Prior Authorization Collaborative Education Request Form and submit to dmepace@noridian.com.

Prior Authorization Timelines

Policy Initial Review
Decision Timeframe
Expedited Review
Decision Timeframe
PAR Decision
Valid
LLP 10 business days 2 business days 120 days
Orthoses 5 business days 2 business days 60 days
PMD 10 business days 2 business days six months
PRSS 5 business days 2 business days one month

Methods of Submission

Affirmative and Non-Affirmative Decisions

After the PA submission goes through the medical review process, the supplier will receive a decision letter, whether affirmative or non-affirmative. These decision letters will be sent to the supplier by mail and can also be obtained from the Noridian Medicare Portal.

For more information on the Prior Authorization Process, please refer to the Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items Operational Guide (cms.gov)

  • Submitters should note that the beneficiary and supplier addresses listed in the PAR will not be used by the DME MACs when sending review decision letters. The decision letters for suppliers will be made electronically available or mailed to the supplier address on file with the NPE and mailed to the beneficiary address on file with the Social Security Administration.
  • When applicable, the prior authorization decision and corresponding claim information may remain with the beneficiary (i.e., the prior authorization decision identified via a Unique Tracking Number, or UTN, may transfer between suppliers). CMS assumes such transfers would be made in accordance with applicable privacy laws.

Resources

Last Updated May 10 , 2024

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