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. Effective for dates of service July 1, 2021, cervical fusion with disc removal and implanted spinal neurostimulators.

A physician’s office can submit a prior authorization request on behalf of the facility. The term requestor will be used throughout this page to describe the person or entity that submits the PA request, 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 PA request with additional supporting information, upon receipt of a non-affirmation, as many times as necessary to achieve an affirmation decision.

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Last Updated Dec 09 , 2023