Prior Authorization for Certain Hospital Outpatient Department (OPD) Services

The Federal Register established a prior authorization (PA) process as a condition of payment for certain cover hospital Outpatient Department Services (OPD). Effective for dates of service July 1, 2020, and after, providers must request prior authorization for the following hospital OPD services: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation.

The hospital OPD provider will submit the PA to their Medicare Administrative Contractor (MAC) jurisdiction. The term requestor will be used throughout this page to describe the person or entity that submits the prior authorization request (PAR), documentation, and/or claims. The MAC will review information submitted and issue the decision (affirmative or non-affirmative) to the provider.

The provider may resubmit a PAR with additional supporting information, upon receipt of a non-affirmation, as many times as necessary to achieve an affirmation decision.

Authorization Process

Review of the PAR

The information submitted will be reviewed by the MAC, and the decision (affirmative or non-affirmative) will be issued to the provider. A provisional affirmation will be issued to the provider if it is decided that applicable Medicare coverage, coding, and payment rules are met. A non-affirmation will be issued to the provider if it is decided that applicable Medicare coverage, coding, and payment rules are not met. A unique tracking number (UTN) will be assigned with each PAR.

Review Decisions and Timeframes

Timeframes for conducting PAR will be dependent upon the service(s) and documentation submitted for PAR. There are three types of review timeframes:

  • Initial Submission- the first PAR sent to the contractor for review and decision. The MAC will complete its review of medical records and send an initial decision letter that is either postmarked or faxed within 10 business days following the receipt of initial request.
  • Resubmission- any subsequent resubmissions to correct an error or omission identified during a PAR decision. A resubmitted PAR is a request submitted with additional/updated documentation after the initial PAR was non-affirmed. The MAC will postmark or fax notification of the decision of these resubmitted requests to the provider or beneficiary within 10 business days of receipt of the resubmission request. The provider should review the detailed decision letter that was provided. A provider may resubmit a PAR an unlimited number of times, upon receipt of a non-affirmative decision. A UTN will be assigned with each PAR resubmission request.
  • Expedited- a PAR decision that is performed on an accelerated timeframe based on the MAC determination that delays in review and response could jeopardize the life or health of the beneficiary. If the MAC substantiates the need for an expedited decision, the MAC will make reasonable efforts to communicate a decision within 2 business days of receipt of the expedited request. The requestor will be notified regarding the acceptance of the PAR for expedited review or if it will convert the request to the standard PAR review process. The affirmative or non-affirmative decision will be rendered within the CMS-prescribed expedited review and will provide the decision to the provider via telephone, fax, electronic portal, or other “real-time” communication, within the requisite timeframe.

    NOTE: The expedited submission should not be used when if the beneficiary’s date of service is soon. This timeframe is to only be used when the patient’s life and health are in jeopardy. The expedited request must include justification showing the standard timeframe would not be appropriated.

    To prevent the claim from denying upon submission, the provider should hold their claim and not submit it until the UTN is provided. The MAC will follow the normal process to obtain a UTN from CMS shared systems.

    A provider may resubmit a request for expedited review.

Decision Letter(s)

The MAC will send decision letters with the UTN to the requester using the method the PAR was received postmarked within the timeframes described above. The MAC will have the option to send a copy of the decision to the requester via fax if a valid fax number was provided, even if the submission was sent via mail. The requester(s) will be notified to hold their claim and not submit until the UTN is received (in order to avoid a claims payment denial).

NOTE: While this prior authorization process is applicable to hospital OPDs, CMS allows the PA request to be sent by the physician/practitioner on behalf of the hospital OPD. If a PA request submitted by the physician/practitioner includes all necessary hospital OPD information, it is considered to be sent on behalf of the hospital OPD.

A copy of the decision letter will be sent to the beneficiary as well.

Decisions

Provisional Affirmation PA Decision
A provisional affirmation PA decision is a preliminary finding that a future claim submitted to Medicare for the service(s) likely meets Medicare’s coverage, coding, and payment requirements.

Non-Affirmation PA Decision
A non-affirmation PA decision is a preliminary finding that if a future claim is submitted to Medicare for the requested service does not likely meet Medicare’s coverage, coding, and payment requirements. The decision letter for an incomplete PAR 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 MAC provider portal (when available).

Provisional Partial Affirmation PA Decision
A provisional partial affirmation PA decision means 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 MAC will follow the same process for any service(s) within the PA request that are given a provisional affirmation decision described above and one or more service(s) received a non-affirmation decision as described above.

Validation Period for Prior Authorization Decisions
PAR decisions and UTNs for these services are valid for 120 days. The decision date shall be counted as the first day of the 120 days. For example: if the PAR is affirmed on January 1, 2021 the PAR will be valid for dates of service through April 30, 2021. Otherwise, the provider will need to submit a new PAR.

Resubmitting a PAR
The requestor may resubmit another complete PAR with all documentation required and whatever modifications are needed, as noted in the detailed decision letter. Unlimited resubmissions are permitted. The requestor is encouraged to include the original non-affirmed UTN on the resubmitted PAR.

Exemptions

CMS may elect to exempt a provider from the PAR upon a provider’s demonstration of compliance with Medicare coverage, coding, and payment rules and that this exemption would remain in effect until CMS elects to withdraw the exemption. CMS or its contractors would exempt providers that submitted at least 10 requests and achieve a PAR provisional affirmation threshold of at least 90 percent during a semiannual assessment. By achieving this percentage of provisional affirmations, the provider would be demonstrating an understanding of the requirements for submitting accurate claims. Notice of an exemption or withdrawal of an exemption will be provided at least 60 days prior to the effective date.

CMS will provide updates to this section in the future.

Suspension of a 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.

Claim Submission

Affirmed PA Decision on File

Cases where a PAR was submitted and a provisional affirmation PA decision was granted, including any service(s) that was part of a partially affirmed decision.

  • The submission of the prior authorized claim is to have the 14-byte UTN that is located on the decision letter. For submission of electronic claims, the UTN must be in positions 1 through 18. When claim enters the Fiscal Intermediary Shared System (FISS), the UTN will move to positions 19 through 32 and zeros will autofill first field.
  • For all other submissions, the provider must TAB to the second field of the treatment authorization field (positions 19-32) and key the UTN. If information is entered into the first field (positions 1 through 18), it will come into FISS as zeros. If the Treatment Authorization Code is entered into the first field, FISS changes the Treatment Authorization code to zeros and the claim will not be accepted. If the UTN is entered into the first Treatment Authorization field, FISS will change the UTN to all zeros. The claim is accepted into FISS with the zeros and without the UTN. The claim will process without the UTN, but will edit for no OPD UTN.
  • Should be submitted to the applicable MAC for adjudication

Note: If all Medicare coverage, coding, and payment requirements are met, the claim will likely be paid.

  • Claims receiving a provisional affirmation may be denied based on either the following:
    • Technical requirements that can only be evaluated after the claim has been submitted for formal processing; or
    • Information was not available at the time of a PAR
    • We note claims for which there is a provisional affirmation PA decision will be afforded some protection from future audits, both pre- and postpayment; however, review contractors may audit claims if potential fraud, inappropriate utilization, or changes in billing patters are identified.

Non-Affirmed PA Decision on File

Cases where a PAR was submitted and a non-affirmed PA decision was granted, including any non-affirmed service(s) that was part of a partially affirmed decision.

  • The submission of the prior authorized claim is to have the 14 byte UTN that is located on the decision letter. For submission of electronic claims, the UTN must be in positions 1 through 18. When the claim enters FISS, the UTN will move to positions 19 through 32 and zeros will autofill the first field. For providers submitting electronic claims, the Medicare Treatment Authorization field must contain blanks or valid Medicare data in the first 14 bytes of the treatment authorization field at the loop 2300 REF02 (REF01=G1) segment for the ASC X12 837 claim.
  • For all other submissions, the provider must TAB to the second field of the treatment authorization field (positions 19-32) and key the UTN. If information is entered into the first field (positions 1 through 18), it will come into FISS as zeros. If the Treatment Authorization Code is entered into the first field, FISS changes the Treatment Authorization code to zeros and the claim will not be accepted. If the UTN is entered into the first Treatment Authorization field, FISS will change the UTN to all zeros. The claim is accepted into FOSS with the zeros and without the UTN. The claim will process without the UTN, but will edit for no OPD UTN.
  • Should be submitted to the applicable MAC for adjudication
    •  If the claim is submitted to the MAC for payment with a non-affirmative PA decision, it will be denied.
    • All appeal rights are then available.
    • This claim could then be submitted to secondary insurance, if applicable.

Claims Submitted without a PA Decision on File

As described in 42 CFR §419.82, if a service requires PA under this program, then submitting a PAR is a condition of payment. Claims for HCPCS code subject to required prior authorization submitted without a prior authorization determination and a corresponding UTN will be automatically denied.

Insurance

NOTE: Whether Medicare is listed as primary or secondary, a prior authorization is required.

Medicare is Primary Insurance

In cases where Medicare is primary and another insurance company is secondary:

The contractors will suspend claims to request documentation and conduct a review of the Advance Beneficiary Notice (ABN) where there is no PAR, and the claim is submitted with the GA modifier appended.

The contractor will determine the validity of the ABN in accordance with standard ABN policies (See IOM 100-04, Chapter 30, Section 40).

Providers who choose to use the PA process to obtain a claim denial should follow the below process:

  • The requester may submit the PAR with complete documentation as appropriate. If all relevant Medicare coverage requirements are not met for the service, then a non-affirmative PA decision will be sent to the provider and beneficiary, advising that Medicare will not pay for the item.
  • After receiving a non-affirmative decision for the PAR, if the associated claim is submitted by the provider to the MAC for payment, it will be denied
  • The provider or beneficiary may forward the denied claim to his/her secondary insurance payer as appropriate to determine payment for the service

In cases where a beneficiary is daily eligible for Medicaid and Medicare, a non-affirmed prior authorization decision is sufficient for meeting states’ obligation to pursue other coverage before considering Medicaid coverage. The provider may need to submit the claim to Medicare first and obtain a denial before submitting the claim to Medicaid for payment.

Another Insurance Company is Primary

Cases where another insurance company is primary and Medicare is secondary:

  • The requester submits the PAR with complete documentation as appropriate. If all relevant Medicare coverage requirements are met for the item(s), then a provisional affirmative PA decision will be sent to the provider and to the beneficiary, if specifically requested by the beneficiary, advising them that Medicare will pay for the service.
  • The provider submits a claim to the other insurance company
  • If the other insurance company denies the claim, the provider or beneficiary can submit a claim to the MAC for payment (listing the unique tracking number on the claim).

Claims Exclusions

The following claim types are excluded from the PA program described in this operational guide unless otherwise specified:

  • 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 subject to PA requirements under the hospital OPD program follow all current appeals procedures. A PAR that is non-affirmed is not an initial determination on a claim for payment for services provided and, therefore, would not be appealable; however, if a provider has an unlimited number of opportunities to resubmit a PAR, provided the claim has not yet been submitted and denied.

A non-affirmation PA decision does not prevent the provider from submitting a claim. Submission of a such a claim and resulting denial by the MAC would constitute an initial payment determination, which makes the appeal rights available.

For further information, please consult Medicare Claims Processing Manual publication, Chapter 29, Appeals of Claims Decision.

Denials for Related Services

Claims related to or associated with services that require PA as a condition of payment will not be paid, if the service requiring PA is not also paid. These related services include, but are not limited to, services such as anesthesiology services, physician services, and/or facility services. Only associated services performed in the OPD setting will be affected. Depending on the time of claim submission for any related services, claims may be automatically denied or denied on a postpayment basis.

Submitting a Prior Authorization Request

Requesters are encouraged to include the following data elements in all Prior Authorization requests to avoid potential delays in processing.

NOTE: Only one date of service per request.

Initial Submission Documentation

Beneficiary Information (as written on their Medicare card):

  • Beneficiary Name
  • Beneficiary MBI
  • Beneficiary Date of Birth

Hospital OPD Information:

  • Name of Facility
  • Part A PTAN/CCN
  • Facility National Provider Identifier (NPI)
  • Facility Address

Physician/Practitioner Information:

  • Physician/Practitioner’s Name
  • Physician/Practitioner’s NPI
  • Physician/Practitioner’s PTAN
  • Physician/Practitioner’s Address

Requester Information:

  • Requester Name
  • Requester Phone Number
  • Requester Address

Other Information:

  • Anticipated Date of Service
  • HCPCS Code(s)
  • Diagnosis Code(s) (providers who submit using esMD must include a diagnosis code(s))
  • Type of Bill
  • Units of Service (providers who submit using esMD must include units of service)
  • Indicate if the request is an initial or subsequent review
  • Indicate if the request is expedited and the reason why

Resubmission(s) Documentation

In addition to the required PAR documentation in the Initial Submission section, the resubmission of the PAR should contain an exact match of the beneficiary’s first name, last name, and date of birth to the previous submission.

Implementation of Prior Authorization

MACs will begin accepting PARs for these services on June 17, 2020, for services provided beginning on or after July 1, 2020.

Sending a Prior Authorization Request

Requester have the following options for submitting PARs to Noridian:

Submissions through esMD will be available July 6, 2020. For more information about esMD, see www.cms.gov/esMD or contact Noridian.

Blepharoplasty

General Documentation Requirements for Blepharoplasty, Eyelid Surgery, Brow Lift, and related services:

  • Documented excessive upper/lower lid skin;
  • Supporting pre-op photos;
  • Signed clinical notes support a decrease in peripheral vision and/or upper field vision;
  • Signed physician’s or non-physician practitioner recommendations
  • Documented subjective patient complaints which justify functional surgery (vision, ptosis, etc.);
  • Visual field studies/exams (when applicable).

Coverage Criteria

Codes

Code Description
15820 Blepharoplasty, lower eyelid
15821 Blepharoplasty, lower eyelid; with extensive herniated fat pad    
15822 Blepharoplasty, upper eyelid
15823 Blepharoplasty, upper eyelid; with excessive skin weighting down lid
67900 Repair of brow ptosis (supraciliary, mid-forehead or coronal approach)  
67901 Repair of blepharoptosis; frontalis muscle technique with suture or other material (eg, banked fascia)
67902 Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia)
67903 Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach
67904 Repair of blepharoptosis; (tarso) levator resection or advancement, external approach
67906 Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia)
67908 Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle-levator resection (eg, Fasanella-Servat type)
67911 Correction of lid retraction

 

Botulinum Toxin Injections

PA is only required when one of the required Botulinum Toxin codes (J0585, J0586, J0587, or J0588) is used in conjunction with one of the required CPT injection codes (64612, injection of chemical destruction of nerve muscles on one side of face, or 64615, injection of chemical for destruction of facial and neck nerve muscles on both sides of face). Use of these Botulinum Toxin codes in conjunction/paired with procedure codes other than 64612 or 64615 will not require PA under this program.

General Documentation Requirements for Botulinum Toxin Injections:

  • Support of medical necessity of the botulinum toxin (type A or type B) injection;
  • A covered diagnosis;
  • Dosage and frequency of the injections;
  • Support for the medical necessity of electromyography procedures performed in conjunction with botulinum toxin type A injections to determine the proper injection site(s) (when applicable);
  • Support of clinical effectiveness of the injections (for continuous treatment);
  • Specific site(s) injected;
  • For support of management of a chronic migraine diagnosis, the Medical Record must include a history of migraine and experiencing headaches on most days of the month;
  • A statement that traditional methods of treatments such as medication, physical therapy, and other appropriate methods have been tried and proven unsuccessful (when applicable)

Coverage Criteria

Codes

Code Description
64612 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm)  
64615 Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine)
J0585 Injection, onabotulinumtoxina, 1 unit
J0586 Injection, abobotulinumtoxina, 5 units
J0587 Injection, rimabotulinumtoxinb, 100 units
J0588 Injection, incobotulinumtoxin a, 1 unit

 

Panniculectomy

General Documentation Requirements for Panniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and related services:

  • Stable weight loss with BMI less than 35 be obtained prior to authorization of coverage for panniculectomy surgery (when applicable);
  • Description of the pannus and the underlying skin;
  • Description of conservative treatment undertaken and its results;
  • The medical records document(s) that the panniculus causes chronic intertrigo or candidiasis or tissue necrosis that consistently recurs over three months and is unresponsive to oral or topical medication (when applicable);
  • Pre-op photograph (if requested);
  • Copies of consultations (when applicable);
  • Related operative report (when applicable);
  • Any other pertinent information.

Coverage Criteria

Codes

Code Description
15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy
15847 Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (list separately in addition to code for primary procedure)
15877 Suction assisted lipectomy; trunk

 

Rhinoplasty

General Documentation Requirements for Rhinoplasty and related services:

  • Medical documentation, with evaluation and management, supporting medical necessity of the service that is to be performed
  • Radiologic imaging if done;
  • Photographs that document the nasal deformity (if applicable);
  • Documentation supporting unresponsiveness to conservative medical management (if applicable)

Coverage Criteria

Codes

Code Description
20912 Cartilage graft; nasal septum
21210 Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)
30400 Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip
30410 Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip  
30420 Rhinoplasty, primary; including major septal repair  
30430 Rhinoplasty, secondary; minor revision (small amount of nasal tip work)  
30435 Rhinoplasty, secondary; intermediate revision (bony work with osteotomies)
30450 Rhinoplasty, secondary; major revision (nasal tip work and osteotomies)
30460 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip only
30462 Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate, including columellar lengthening; tip, septum, osteotomies
30465 Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction)  
30520 Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft

 

Vein Ablation

General Documentation Requirements for Vein Ablation and related services:

  • Doppler ultrasound;
  • Documentation stating the presence or absence of DVT (deep vein thrombosis), aneurysm, and/or tortuosity (when applicable);
  • Documented Incompetence (reflux greater than 500msec) of the valves of the Saphenous, Perforator or Deep venous systems consistent with the patient’s symptoms and findings (when applicable);
  • Photographs if the clinical documentation received is inconclusive;
  • The patient’s medical record must contain a history and physical examination supporting the diagnosis of symptomatic varicose veins (evaluation and complains), and the failure of an adequate (at least 3 months) trial of conservative management (before the initial procedure).

Coverage Criteria

Codes

Code Description
36473 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; first vein treated
36474 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, mechanochemical; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)   
36475 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated
36476 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)   
36478 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated
36479 Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)
36482 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; first vein treated
36483 Endovenous ablation therapy of incompetent vein, extremity, by transcatheter delivery of a chemical adhesive (eg, cyanoacrylate) remote from the access site, inclusive of all imaging guidance and monitoring, percutaneous; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure)

 

Advance Beneficiary Notice of Noncoverage (ABN)

If an applicable claim is submitted without a PAR decision and is flagged as having an 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. Please review information on the Noridian Advance Beneficiary Notice Of Noncoverage (ABN) webpage. The table below describes modifiers used for billing services in certain situations.

Modifiers

Modifier Description
GA Modifier Waiver of liability statement issues, as required by payer policy. Advanced Beneficiary Notice (ABN) of liability required. Modifier is used to signify a line item is linked to the mandatory use of an ABN when charged both related to and not related to an ABN must be submitted on the claim. Line item must be submitted as covered, and Medicare will make the determination for payment.
GZ Modifier Item or service expected to be denied as not reasonable and necessary. Cannot be used when ABN is given. Lines submitted as non-covered will be denied as provider-liable.
GY Modifier Item or service is statutorily excluded or does not meet the definition of any Medicare benefit. Lines submitted as non-covered and will be Patient Responsibility (PR).

Cosmetic Services

Please refer to the following regarding cosmetic services:
CMS Internet Only Manual (IOM), Publication 100-02, Chapter 16, Section 120 Cosmetic Surgery

Resources

Prior Authorization for Certain Hospital Outpatient Department (OPD) Services (CMS)
Federal Register

 

Last Updated Mon, 24 Aug 2020 19:13:20 +0000