Prior Authorization for Power Mobility Devices

Due to the CMS final rule 42 CFR §§405 and 414., in 2016, a Condition of Payment Prior Authorization (COPPA) process for certain DMEPOS that are frequently subject to unnecessary utilization was established. It began with two PMD HCPCS codes, K0856 and K0861, and as of 2019 encompasses 40 PMD HCPCS codes.

Effective nationwide April 13, 2022, prior authorization (PA) will be required for five power operated vehicle codes: K0800, K0801, K0802, K0806, K0807, and K0808.

PA requests may be submitted March 30, 2022, for dates of delivery on or after April 13, 2022, to enable submitters time to test their systems and processes to ensure successful PA submissions.

Access the below related information from this page.

Documentation to Include in Submission

  • Face-to-Face Evaluation (F2F)
    • Medical records addressing beneficiary's mobility related abilities and policy criteria
  • Written Order Prior to Delivery (WOPD)
  • Specialty Evaluation
    • Performed by a licensed/certified medical professional (LCMP)
    • Documents medical necessity for wheelchair and its special features
    • Documents no financial relationship between LCMP and supplier
  • RESNA-Certified Assistive Technology Professional (ATP)
    • Documents in-person involvement in wheelchair selection
    • Documents ATP credentials
  • Any additional medical records providing support for medical necessity

Documentation must be submitted with PA Request cover sheet via the Noridian Medicare Portal, fax, mail, or esMD to the appropriate jurisdiction.

To ensure process efficiency, assure all components are completed and included within the submission.

Follow the order of events and the documentation required when submitting a PA package.

PA requests will be reviewed within 10 business days.

Expedited Request Guidelines

In very rare emergent circumstances an expedited review may be requested. To be processed as an expedited request, circumstances must be in accordance with the following guidelines:

  • Expedited request must be accompanied by supporting medical documentation
  • Physician indicates clearly, with supporting rationale, that the 10-business day timeframe for an initial decision could jeopardize the beneficiary's life or health

When documentation does not support the above guidelines, expedited requests will be reviewed within the standard timeframe.

Avoid Request Rejections

There are various reasons why a PA may be rejected and not reviewed. Proper completion of the PA coversheet and a thorough intake process aids in minimizing most rejections. Common reasons include:

  • HCPCS code is not subject to prior authorization
  • Beneficiary does not reside in this jurisdiction
  • Duplicate to a previous prior authorization request

Affirmative and Non-Affirmative Decisions

After the PA submission goes through the medical review process, the supplier with receive a decision letter.

Affirmative Based on the review, it was determined the beneficiary meets the medical necessity requirements established by Medicare for the PMD base requested.

Process:
  • Complete a home assessment
  • Deliver PMD and obtain Proof of Delivery
  • Bill with correct Unique Tracking Number (UTN)
Once an affirmed decision has been made, submit the claim. Include the 14-byte UTN, provided within the decision letter, as indicated below.
  • If billing on CMS-1500 Claim Form, include UTN in Item 23
  • If billing electronically, include UTN in loop 2300 REF02 (REF01 = G1) or loop 2400 REF02 (REF01 = G1)
Non-Affirmative Based on the review, a supplier is required to follow-up prior to submitting a resubmission.

Options:
  • Review decision and resubmit a PA resubmission
    • Gather missing and/or clarifying documentation and resubmit
    • Able to submit unlimited resubmissions
  • Deliver PMD and submit claim for denial
    • Execute Advance Beneficiary Notice of Non-coverage (ABN) prior to delivery, if appropriate
    • File an appeal
  • Do not deliver or bill

 

Decision Letters

Treating practitioners involved in the submission of a prior authorization may request a copy of the decision letter.

  • Treating practitioner requesting the letter must be able to demonstrate a legitimate, specific need for information requested
  • Request may be sent in with PA request or separately

Still Have Questions?

Call the Supplier Contact Center or Interactive Voice Response (IVR), or Pre-Claim Hotline.

Resources

 

Last Updated Thu, 15 Sep 2022 14:24:26 +0000