Prior Authorization for Pressure Reducing Support Surfaces

The CMS final rule 42 CFR §§405 and 414., in 2016, established a Prior Authorization (PA) process for certain DMEPOS that are frequently subject to unnecessary utilization. In 2019 it expanded nationwide to include Pressure Reducing Support Surfaces (PRSS) HCPCS codes E0193, E0277, E0371, E0372, and E0373 for new rental series claims.

Prior Authorization Timelines

Policy Initial Review Decision Timeframe Expedited Review Decision Timeframe PAR Decision Valid
PRSS 5 business days 2 business days one month

Access the below related information from this page.

Documentation to Include in PA Package Submission

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

PA requests for PRSS will be reviewed within five business days.

Methods of Submission

Expedited Request Guidelines

In very rare emergent circumstances, an expedited review may be requested. An expedited request is when the five-day review timeframe for a PA decision could jeopardize the life or health of a beneficiary.

  • One possible scenario, as indicated in The Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items-Operational Guide is a beneficiary who has a diagnosis of a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days.

To be processed as an expedited request, ensure the following information is provided.

  • Request must be accompanied by medical documentation to support above requirements
  • On coversheet, indicate that it is an expedited request and provide justification in one or two sentences
  • To prevent delays, it is recommended to use fax, esMD, or DME MAC portal when submitting expedited requests

When a request supports the above guidelines, the DME MAC will make reasonable efforts to communicate a decision within two business days of the receipt of the expedited request.

Tips to Prevent an Expedited Request

  • Work with referral sources to establish the necessity of an item prior to an immediate need.
  • Discharge planning begins on admission to an acute care facility. Gather necessary documentation prior to day of discharge to prevent delays.

When documentation does not support the above guidelines, expedited requests will be downgraded to standard requests.

Avoid Request Rejection

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

  • HCPCS code is not subject to prior authorization
  • Duplicate to a previous PA request
  • The beneficiary does not reside in this jurisdiction based on the beneficiary's permanent address

Affirmative and Non-Affirmative Decisions

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

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 and jurisdiction). CMS assumes such transfers would be made in accordance with applicable privacy laws.

Affirmative

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

Process:

  • Deliver PRSS and obtain Proof of Delivery
    • The affirmation decision is valid for one month from the date on the decision letter.
    • If the item is not delivered within one month, a new PA request must be submitted.
  • Bill with correct Unique Tracking Number (UTN) located in decision letter
  • Bill with appropriate ICD-10 code

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)
  • Continue to bill with the UTN for all 13 rental months

Non-Affirmative

Based on the review, a supplier is required to follow-up prior to submitting a resubmission.

Options:

  • Review decision and submit a PA resubmission
    • Gather missing and/or clarifying documentation and resubmit
    • Able to submit unlimited resubmissions
  • Deliver PRSS and submit claim for denial
    • Execute Advance Beneficiary Notice of Non-coverage (ABN) prior to delivery, if appropriate
  • 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, Interactive Voice Response (IVR), or Pre-Claim Hotline.

Resources

Last Updated Nov 11 , 2024