Part A OPD Prior Authorization Process - JE Part A
Part A OPD Prior Authorization Process
Authorization requests are required for hospital outpatient departments billing using a valid Part A PTAN on a type of bill 13X. The hospital outpatient provider will submit the PA to their Medicare Administrative Contractor (MAC) jurisdiction. Information submitted will be reviewed by the MAC, and the decision (affirmative or non-affirmative) will be issued to the provider. A unique tracking number (UTN) will be assigned with each PAR.
The term requestor will be used throughout this page to describe the person or entity that submits the prior authorization request (PAR).
Suspension of PA Process
CMS may suspend the OPD services PA process requirement generally or for a particular service(s) at any time by issuing a notification on the CMS website.
Step 1: Request Submission
Submit the Part A OPD prior authorization request via one of the methods listed. If submitting request by mail or fax, it is suggested to use Noridian's Part A Authorization Request Coversheet.
- Fax
- Noridian Medicare Portal
- esMD
Note: The Noridian Medicare Portal supports both Part A and B, but access is role specific. Part B users must obtain approved Part A access to submit requests for Part A OPD facilities. Requests cannot be submitted through the Part B portal. To request access, contact your Provider Contact Center. More details are in the Noridian Portal Guide.
Step 2: Submission Review
Noridian reviews prior authorization requests within 7 calendar days for normal requests and 2 business days for expedited requests. Expedited requests must meet expedited criteria as outlined in CMS OPD Operational Guide.
- Expedited - An expedited PAR decision is made on an accelerated timeline when delays could jeopardize the beneficiary's life or health. The expedited request must include justification showing the standard timeframe would not be appropriate. If the MAC confirms the need, it will aim to issue a decision within 2 business days of receiving the request. The requester will be notified whether the expedited review is accepted or converted to standard processing. The final decision-affirmative or non-affirmative-will be delivered within CMS-prescribed timeframes via real-time communication methods such as phone, fax, or electronic portal. Expedited requests may be resubmitted for review.
Step 3: Decision
The request will result in 1 of 4 decisions. The MAC will send decision letters with the UTN to the requester using the method the PAR is received. A copy of the decision letter will be sent to the beneficiary as well. Providers have an unlimited number of times to resubmit a request to achieve an affirmation.
- Affirmation - Preliminary finding that a future claim submitted to Medicare for the service(s) likely meets Medicare's coverage, coding, and payment requirements.
- Partial Affirmation - Preliminary finding that one or more service(s) on the PAR received a provisional affirmation decision and one or more service(s) received a non-affirmation decision. The decision letter will be detailed, and the MAC will provide the PAR requester notification of what required documentation is missing or noncompliant with Medicare requirements via fax, mail, or the MAC provider portal.
- Non-Affirmation - Preliminary finding that the requested service is unlikely to meet Medicare coverage, coding, and payment requirements. The decision letter will explain what documentation is missing or not compliant, with notice sent via fax, mail, or provider portal. The MAC will provide the PAR requester notification of what required documentation is missing or non-compliant.
- Rejection - The request can't be reviewed due to missing or incorrect information (e.g., invalid PTAN/NPI, incorrect patient info, missing identifiers, or non-covered codes). The decision letter will specify the reason. Please be sure to read your decision letter to determine the reason for rejection.
Step 4: Service Delivery
If a request is awarded an affirmation determination, the provider can proceed with delivering services/procedures approved for the beneficiary. A valid prior authorization request UTN is valid for 120 days with date of decision counted as day 1.
Step 5: Claim Submission
The claim is submitted to Medicare for payment. This process helps ensure that treatments are medically necessary, controlling costs and preventing unnecessary healthcare services.
ABN Modifiers
If an applicable claim is submitted without a PAR decision and is flagged as having an Advance Beneficiary Notice Of Noncoverage (ABN), it will be stopped for additional documentation to be request and a review of the ABN will be performed (to determine the validity of the ABN) following standard claim review guidelines and timelines. ABN related modifiers are found within the Waiver of Liability Modifiers section of the Modifiers webpage.
Insurance and Prior Authorization
A Prior Authorization is required regardless of whether Medicare is the primary or secondary payer.
When Medicare is Primary
- If no PAR is submitted and the claim includes a GA modifier, the MAC will suspend the claim to review the Advance Beneficiary Notice (ABN) for validity, per CMS guidelines (see CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 40).
- Providers may submit a PAR to obtain a non-affirmative decision as documentation for denial.
- After receiving a non-affirmation, the provider may submit the claim to Medicare for formal denial.
- The claim denied can then be forwarded to secondary insurance for consideration.
- For beneficiaries eligible for both Medicare and Medicaid, a non-affirmed PA decision may satisfy Medicaid's requirement to pursue other coverage first.
When Medicare is Secondary
- Submit the PAR with full documentation.
- If Medicare coverage criteria are met, a provisional affirmation will be issued.
- The provider should first bill the primary insurer.
- If the primary insurer denies the claim, it can then be submitted to Medicare with the UTN for payment consideration
