Part A OPD Prior Authorization Claim Submission - JE Part A
Part A OPD Prior Authorization Claim Submission
Prior Authorization (PA) Decision and Claim Submission
Affirmed PA Decision on File
Applies when a Prior Authorization Request (PAR) receives a provisional affirmation, either fully or partially.
- Claim Submission:
- Include the 14-byte Unique Tracking Number (UTN) from the decision letter.
- Electronic Claims: Enter UTN in positions 1-18; it will shift to positions 19-32 in FISS.
- Other Submissions: Enter UTN directly in positions 19-32.
- Incorrect placement (positions 1-18) results in UTN being replaced with zeros, causing the claim to process without the UTN and triggers an edit for missing OPD UTN.
- Adjudication: Submit to the appropriate Medicare Administrative Contractor (MAC).
- Outcome: If all Medicare requirements are met, the claim is likely to be paid.
- Audit Protection: Some protection from audits, but claims may still be reviewed for fraud, misuse, or billing anomalies.
Non-Affirmed PA Decision on File
Applies when a PAR was submitted but received a non-affirmed decision, either fully or partially.
- Claim Submission:
- Same UTN placement rules as above.
- For electronic claims, ensure the first 14 bytes of the Treatment Authorization field contain valid Medicare data or blanks.
- Adjudication: Submit to the applicable MAC.
- Outcome: Claims with a non-affirmed PA decision will be denied.
- Next Steps: Providers may pursue appeal rights or submit the claim to secondary insurance, if applicable.
No PA Decision on File
Applies when a required PAR was not submitted.
- Regulatory Basis: Under 42 CFR §419.82, submitting a PAR is a condition of payment for services requiring prior authorization.
- Outcome: Claims submitted without a PA decision and UTN will be automatically denied.
Claims Exclusions
Unless otherwise specified, the following types of claims are not subject to the Prior Authorization (PA) program outlined in this operational guide:
- Veterans Affairs
- Indian Health Services
- Medicare Advantage
- Part A and B Demonstration
- Medicare Advantage sub-category IME only claims
- Part A/B rebilling
Claim Appeals
Claims under the Hospital OPD Prior Authorization (PA) program follow standard Medicare appeals procedures.
A non-affirmed PAR is not appealable, as it is not a payment determination. However, providers may resubmit the PAR any number of times before the claim is submitted and denied. If a claim is submitted after a non-affirmation and denied by the MAC, that denial becomes an initial determination, making it eligible for appeal.
For more details, refer to the Medicare Claims Processing Manual, Chapter 29.
Denials for Related Services
If a service requiring PA is not paid, any related OPD services (e.g., anesthesiology, physician, or facility services) will also be denied. These denials may occur automatically or on a post payment basis, depending on claim timing.
Cosmetic Services
Please refer to the following regarding cosmetic services:
CMS Internet Only Manual (IOM), Publication 100-02, Chapter 16, Section 120 Cosmetic Surgery
