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Prior Authorization

CMS has implemented prior authorization as a condition of payment for specific HCPCS codes. Information regarding these items and their requirements are listed below under Required Programs.

There is currently a PMD Demonstration effective until August 31, 2018. Information regarding this demonstration can be found below under Power Mobility Device (PMD) Demonstration.

Topic Brief Description
Power Mobility Device (PMD) Demonstration Prior Authorization Request (PAR) process for designated Power Mobility Devices (PMDs) for Medicare beneficiaries within Jurisdiction D.
Required Programs For dates of Service March 20, 2017 and after, CMS has implemented a PAR process for the K0856 Group 3 Single Power Option and K0861 Group 3 Multiple Power Option Power wheelchairs.

 

Condition of Payment Prior Authorization (PA) Program vs. PMD PA Demonstration Comparison

The following table summarizes the key differences between the Condition of Payment Prior Authorization (PA) Program and the current PMD PA Demonstration. The following two HCPCS codes were chosen to begin the Condition of Payment PA Program:

  • K0856- POWER WHEELCHAIR, GROUP 3 STANDARD, SINGLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS
  • K0861- POWER WHEELCHAIR, GROUP 3 STANDARD, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS.

CMS may implement additional states and HCPCS codes for PA consideration in the future.

 

Condition of Payment PA Program

PMD PA Demonstration

States

Dates of Service 3/20/17 and after:

  • JA: NY
  • JB: IL
  • JC: WV
  • JD: MO

Dates of Service 7/17/17 and after:

  • Nationwide
  • JA: NY, MD, NJ & PA
  • JB: IL, MI, IN, KY & OH
  • JC: FL, NC, TX, GA, TN & LA
  • JD: CA, MO, WA & AZ

HCPCS Codes

K0856 and K0861

K0800-K0802, K0812-K0829, K0835-K0843, K0848-K0855, K0890-K0891, K0898

Requests Accepted From

A beneficiary residing in one of the participating states or a DME supplier.

A beneficiary residing in one of the participating states, a DME supplier, or a physician.

Decisions

Initial Request: 10 business days
Subsequent Request: 20 business days
Expedited Request: 2 business days

Initial Request: 10 business days
Subsequent Request: 20 business days
Expedited Request: 2 business days

PA Decision Letter Recipients

Beneficiary (if specifically requested) and supplier

Supplier, physician and beneficiary

Resubmissions

Unlimited

Unlimited

Payments

Any claim eligible for this program must be prior authorized before delivery of the item or it will be denied as prior authorization is a condition of payment.

Claims billed that are eligible for the demonstration will undergo complex medical review if prior authorization is not utilized.

  • CBA Supplier: Designated single payment amount.
  • Non-CBA Supplier: A 25% reduction of Medicare payment after co-insurance and deductible applied.

Appeals

The standard appeals process applies when the claim is denied due to no PAR submitted, in addition to:

  • No GA modifier appended on the claim (CO denial).
  • GA modifier is appended and Advance Beneficiary Notice of Noncoverage (ABN) deemed missing or invalid (CO denial)
  • GA modifier is appended and ABN deemed valid (PR denial).

Payment reduction is not eligible for appeal. The standard appeals process applies when:

  • The claim is billed with a non-affirmative PAR decision on file.
  • The claim is denied after complex medical review and no prior authorization on file.

 

Last Updated May 26, 2017