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Power Mobility Device (PMD) Prior Authorization Demonstration Project

On September 1, 2012, the Medicare Fee-For-Service Program began conducting a three-year prior authorization demonstration project for certain Power Mobility Devices (PMD). In Jurisdiction B, this demonstration project applies to beneficiaries permanently residing in Illinois and Michigan.

Effective October 1, 2014, the demonstration was expanded to included beneficiaries permanently residing in the states of Indiana, Kentucky, and Ohio.

The prior authorization process under this demonstration is available for PMD orders written on or after September 1, 2012, for IL and MI, and October 1, 2014, for IN, KY, and OH, for the following Healthcare Common Procedure Coding System (HCPCS) codes:

A Prior Authorization Request (PAR) may be submitted by either the treating physician/practitioner or the supplier. Before sending the request, the submitter should complete a Prior Authorization Request Coversheet (see link above). The PAR must include the following documentation:

The request may be mailed or faxed as follows:

Fax the PAR to: 615-660-5992
Mail the PAR to: CGS – DME Medical Review – Prior Authorization
PO Box 23110
Nashville, TN 37202-4890

After receipt of all relevant documentation, CGS will review and communicate a decision within 10 business days. The decision letter regarding prior authorization (affirmative or non-affirmative) will be sent to the treating physician/practitioner, the supplier and the Medicare beneficiary. In the event of a non-affirmative decision, the letter will explain why the PAR was not affirmed. The letter will additionally provide a prior authorization tracking number that should be submitted with the PMD claim.

Please note that prior authorization is not mandatory. However without a prior authorization decision, if a claim for one of the HCPCS codes listed above is submitted for a beneficiary residing in any of the demonstration states listed above, the claim will be stopped for review. At that time, CGS will send the supplier an Additional Documentation Request (ADR) letter and the supplier must respond within 45 days by providing all requested documentation. Additionally, starting December 1, 2012, CMS will assess a 25 percent payment reduction on a supplier's payable claim when the first claim is not preceded by a PAR.

There is an exception to the 25 percent reduction in payment for competitive bidding contract suppliers submitting a payable claim for a beneficiary with a permanent residence in a competitive bidding area. The competitive bid supplier will receive the contractual single payment amount under their contract. These suppliers, however, must adhere to all other requirements of the demonstration.

For additional information concerning the PMD prior authorization demonstration project, please refer to the above web links.

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