Part B Provider Responsibility for Prior Authorization (PA) for Certain Hospital Outpatient Department (OPD) Services

Noridian has been receiving requests for prior authorizations from Part B providers, who bill on the CMS-1500 form.

This program is for outpatient hospital services billed on a UB-04 form, with type of bill 13X. Providers who bill on a CMS-1500 form should not submit prior authorization requests for the OPD services because it is the facility’s responsibility to send in the request. A valid prior authorization request must contain the Part A Provider Transaction Access Number (PTAN), which is six digits. Requests that come from a physician’s office will be rejected.

It is the physicians’ responsibility is to assist the facility by ensuring copies of the patient’s medical records are available for the following services:

  • Blepharoplasty
  • Botulinum Toxin Injections - use for chronic migraine treatment
  • Panniculectomy
  • Rhinoplasty
  • Vein Ablation

Physicians must ensure the services support medical necessity. Noridian has policies covering each of these services listed above and can be located on the Active LCDs Webpage.

Please provide the listed elements located on the Jurisdiction E Part A Prior Authorization OPD Webpage upon request.

In CMS MLN Connects for June 11, 2020, OPD services require PA as a condition of payment. The article states, “While only the hospital OPD services requires prior authorization, CMS wants to remind providers that perform services in the hospital OPD setting that claims related to or associated with these services will NOT be paid if the service requiring PA is not eligible for payment. These related services include, but are not limited to, anesthesiology services, physician services, and facility services. Only associated services performed in the OPD setting are affected. Depending on the timing of claim submission for any related services, claims may be automatically denied or denied on a postpayment basis.”


            Last Updated Tue, 21 Jul 2020 14:30:54 +0000