Part B ASC Prior Authorization Claim Submission - JE Part B
Part B ASC 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: When submitting an electronic 837 professional claim for a prior authorized service, include the UTN in the 2300 loop's REF segment using qualifier "G1" (REF01) and the UTN (REF02). This applies to the entire claim unless overridden in the 2400 loop. This follows ASC X12 837 TR3 guidelines.
- Paper Submissions: For paper CMS 1500 claims, enter the UTN in the first 14 positions of item 23. Any additional data in item 23 must start in position 15.
- 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 for electronic and paper submissions as above.
- 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 (Prepayment claim review)
Prior authorization is optional. Claims without a PAR decision will be held for prepayment review. ASCs can submit claims as usual without a UTN.
Prepayment Review: The MAC will determine claim eligibility before payment. ASCs will receive an ADR via mail or electronically and have 45 days to respond by Noridian Medicare Portal, fax, mail, or esMD.
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
- Medicare Advantage sub-category IME only claims
- Railroad Retirement Board
Claim Appeals
Claims under the ASC demonstration 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.
A claim submitted without a UTN, which results in a prepayment review including an ADR, has appeal rights available if the medical review decision is a denial.
For more details, refer to the CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 29.
Denials for Related Services
If a service requiring PA is not paid, any related ASC 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 IOM, Publication 100-02, Medicare Benefit Policy Manual , Chapter 16, Section 120 Cosmetic Surgery
