CMS Prior Authorization Update Affects Outpatient Services

Thoughtware Alert Jul 01, 2020
Healthcare CMS

CMS is establishing a nationwide prior authorization process and requirements for certain hospital outpatient department (OPD) services. The requirement went into effect nationally for services rendered on or after July, 1, 2020, and Medicare Administrative Contractors (MAC) began accepting authorization requests on June 17, 2020

What providers and services will be affected by the new authorization requirements?  

  • Affected providers are hospital OPD reporting services on a type of bill 13X and paid by the Hospital Outpatient Prospective Payment System (OPPS). This requirement does not apply to critical access hospitals or AmbSurg facilities.
  • Prior authorizations (PA) will be required for 43 individual CPT/HCPCS codes in procedure categories below:

OPD Services Requiring PA & CPT/HCPCS Codes

How are providers required to submit authorization requests? 

Providers have multiple options for submitting PARs: 

  • Mail
  • Fax
  • Submission through the Electronic Submission of Medical Documentation System (esMD), content type 8.5
  • Submission via your MAC’s portal

How long will it take to receive a determination from the MACs?

  • Initial requests: Approval determinations will be postmarked, faxed, or delivered electronically within 10 business days.
  • Resubmitted requests: Determinations will be postmarked, faxed, or delivered electronically within 10 business days.
  • Expedited requests: If it is determined that delays in receipt of a prior authorization decision could jeopardize the life, health, or ability to regain maximum function of the beneficiary, then the MAC will process the prior authorizations request under an “expedited” timeframe, upon request. The MAC will communicate the determination within two business days of receipt.

How will a determination be received and what will be included?

  • MACs will send a letter providing their prior authorization decision to the requestor and the beneficiary via the same method the request was sent.
  • One of three decisions will be made:
    • Provisional Affirmation Decision – A provisional affirmation decision is a preliminary finding that a future claim submitted to CMS for the service(s) likely meets CMS’s coverage, coding, and payment requirements. The provisional affirmation prior authorization is valid for 120 days from the date the decision was made.
    • Provisional Partial Decision – One or more service(s) on the prior authorization request (PAR) received a provisional affirmation decision and one or more service(s) received a nonaffirmation decision.
    • Nonaffirmation Decision – This is a preliminary finding that a future claim submitted to Medicare for the requested service(s) does not likely meet Medicare’s coverage, coding, and payment requirements.
  • Decision letters will contain a Unique Tracking Number (UTN)

How can you resolve nonaffirmation or provisional partial decisions? 

These decisions can be resolved in one (but not both) of the following ways:

  • The requestor can resolve the nonaffirmation reasons detailed in the decision letter and may resubmit the PAR. A nonaffirmation prior authorization request decision is not appealable; however, unlimited resubmissions are allowed.
  • The requestor can forego the resubmission process, provide the hospital OPD service, and submit the claim for process but understand the claim will be denied. All appeal rights are available.

What needs to be included on the claim related to the authorization? 

  • Claims submitted must contain the UTN to receive payment.  
  • For resubmitted requests, the UTN associated with the previous submission must be included.
  • Claims submitted for services subject to required prior authorization without the appropriate prior authorization decision and corresponding UTN will automatically be denied.

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