Beginning July 1, 2020 providers must submit a prior authorization (PA) request to the Medicare Administrative Contractor (MAC) for any service on the list of outpatient department (OPD) services requiring PA as a condition of Medicare payment.

Providers must request PA for the following 5 categories/groups of HOPD services and related services before the any of the below are rendered:

• Blepharoplasty
• Botulinum toxin injections
• Panniculectomy
• Rhinoplasty
• Vein ablation

Prior Authorization Program Overview

The PA Program is a nationwide program that includes Medicare Fee-For-Service (FFS) enrolled hospital outpatient departments (HOPDs) that provide certain services. A Requestor, or a person/entity submitting a prior authorization request (PAR), documentation, and/or claims, must submit a PAR to their Medicare FFS contractor, for example NGS, who will then review the PAR and issue a decision letter to affirm or disavow the procedure. On 6/17/2020, MACs will start to accept PARs for services provided on or after 7/1/2020. Claims on a CMS-1500 form do not apply to this PA process.

As noted above, the current list of services that require a PAR is limited; however, CMS indicated it could expand the list of HOPD services that require a PA in the future through formal notice-and-comment rulemaking procedures.

PAR Types

There are three types of PAR submissions. The response time from NGS varies for each as follows:

• Initial:
  • The MAC will respond with affirmation or non-affirmation letter typically within 10 business days.
• Expedited:
  • Only utilized in emergency situations and then NGS will make a determination if the life or health of the person is in jeopardy based on all information apart of the initial PAR request usually within 2 business days or less.
• Resubmission:
  • PARs can be resubmitted an unlimited amount of times after a letter of non-affirmation is received and NGS will respond within 10 business days to each resubmission.

For any questions regarding the Prior Authorization Program, when its required, how to use prior authorization, or any other health care regulatory and/or operational matters, please contact Advis or call 708.478.7030.

Published: June 29, 2020