Available For: Part A Outpatient Department (OPD) Hospital Services

Part A users may submit a request for a new Prior Authorization by completing the following instructions on NMP. Prior Authorizations are only required for certain Hospital Outpatient Department (OPD) services and WISeR Model services (Arizona and Washington providers only).

To view a list of WISeR Model CPT Codes that may require Prior Authorization and more information on the WISer Model visit the WISeR Model page.

Submit New Prior Authorization Request

Choose Prior Auth/Pre-Claim from the Main Menu and then the Submit New PA/Pre-Claim Tab.

Provider/Supplier Details

Directions: Choose the Provider/Supplier Details of the OPD facility for which you are submitting, and the Unique Tracking Number (UTN) will be assigned. Your NMP account must be registered with this information to review the request after submission.

• TIN or SSN
• NPI
• PTAN - Ensure MEDA is selected

Prior Authorization Type

Directions: Choose "OPD"

Physician/Provider Details

Directions: Enter the information for the OPD provider that will perform services.

• Provider Name
• Provider PTAN
• Provider NPI
• Provider Address
• Provider City
• Provider State
• Provider Zip
• Provider Fax Number (Not Required)

Beneficiary Details (As it appears on Medicare Card)

Directions: Enter the beneficiary information as it appears on their Medicare card. Ensure all submitted medical records have the same spelling and date of birth as entered.

• Medicare Number
• First Name
• Last Name
• Date of Birth
• State of Residence

Requestor Details

Directions: The requestor is the individual submitting the request (e.x. office manager or claim specialist).

• Requestor Full Name/Provider Name
• Requestor Phone
• Requestor Email Address
• Requestor Fax Number
• Requestor Address
• Requestor City
• Requestor State
• Requestor Zip Code

Facility Details

Directions: Enter the OPD facility information as entered in the Provider/Supplier Details section. These fields must match.

• Facility Name (Auto-populated)
• Facility Address
• Facility City
• Facility State
• Facility Zip Code
• Facility NPI (Auto-populated)
• Facility PTAN (Auto-populated)

Prior Authorization Request Details

• Procedure Code
• Number of Units
• Anticipated Date of Service
• Diagnosis Code
• Type of Bill
• Initial Request or Resubmission? If resubmission, enter the previous UTN.
• Expedited Request?

Upload Supporting Document

Ensure all medical records contain the correct beneficiary's name and date of birth.

Upload Requirements:

Maximum File Size: 70 MB

Supported Formats: GIF, JPG, JPEG, TIF, TIFF, DOC, DOCX, XLS, XLSX, PDF

File Name Limit: 40 characters (use a descriptive name to identify the document and its purpose)

Once all documentation is attached, select Submit.

Once the request has been submitted, a Reference Number will be provided. Additional supporting documentation may be uploaded after 15 minutes to allow the initial request to process.

To upload additional documentation or check status, perform a Prior Authorization Status Inquiry.

Prior Authorization Request Status

Part A users may check the status of OPD Prior Authorization requests, view the reviewer notes and add/view related documents. Note: Allow 15 minutes after initial request has been submitted to view the status.

Status inquiries on WISeR Model Prior Authorization Requests CAN NOT be performed in NMP. Users may reach out to your assigned WISeR model participant.

• Arizona - Zyter Trucare
• Washington - Virtix Health

Inquiry

Provider/Supplier Details

Directions: Select the same provider information used during submission in the Provider/Supplier Details. Your NMP account must be registered with the OPD details to view the submission.

• TIN or SSN
• NPI
• PTAN
• Program - Ensure MEDA is selected

Beneficiary Details (As it appears on Medicare Card)

Directions: Enter the beneficiary information used on the original request.

• Medicare Number
• First Name
• Last Name

Prior Authorization Request Details

• HCPCS - Enter the CPT/HCPCS code that was used on the request

Choose Submit Inquiry.

Response

The following details will be available:

• Unique Tracking Number (UTN)
• Reference Number
• Receipt Date
• Complete Date
• Review Status
• Decision
• Medical Review Notes - View notes from prior authorization request reviewer
• Related Documents - View documents associated with the request. This includes the decision letter. Additional documentation may be uploaded 15 minutes after submission.

Prior Authorization Exemption Inquiry

There are no exemptions available for WISeR Model providers at this time.

Inquiry

• Choose Exemption Inquiry tab under Prior Auth/Pre-Claim.
• Choose TIN, NPI and PTAN if needed.
• Choose Submit Inquiry

Response

The response page provides a summary of the provider information that was used in the search.

Below that the Portal provides the following:

• Letter Date
• Reference Number
• Download Letter
  • Choose the download link to view a copy of the Prior Authorization Exemption letter.