Power Mobility Devices (PMDs) Condition of Payment Prior Authorization - What Suppliers Need to Know
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July 10, 2017Revised 12.17.19

Power Mobility Devices (PMDs) Condition of Payment Prior Authorization - What Suppliers Need to Know

Q: What is the timeframe for delivery of a power wheelchair under the Condition of Payment Prior Authorization process?

A: The delivery of the PMD that has received a Condition of Payment affirmative determination must be within six (6) months following the determination.

Q: What are the review timelines for a PMD prior authorization request?

A: The DME MACs will complete their review of an initial PAR and send a detailed decision letter postmarked or faxed by the 10th business day following the DME MAC's receipt of the PAR. For PARs that are resubmitted after the initial PAR was non-affirmed (i.e., resubmissions that correct curable errors or add previously missing documentation), the DME MAC will complete their review and send a detailed decision letter postmarked or faxed by the 20th business day of receipt of the PAR.

Q: Does the DME MAC review for same or similar items as part of the Prior Authorization Request (PAR) process?

A: Yes, the DME MAC will check if the patient has previously received the same or similar piece of equipment and the item has not yet reached its reasonable useful lifetime period as part of the PAR.

Q: Will accessories of the affected power wheelchair codes be subject to prior authorization?

A: Accessories for the affected codes are not separately subject to prior authorization. Only the base will be listed on the affirmation.

When the specialty evaluation supports the need for specific options/accessories that are needed to address a Medicare patient's particular limitations, these options/accessories will be considered as part of the PAR however they will not receive a separate affirmation.

Q: Can accessories still be sent for ADMC if the wheelchair is included in the Condition of Payment Prior Authorization?

A: No, accessories for the affected  codes are not separately subject to ADMC.

Q: Are there any exceptions to the Condition of Payment Prior Authorization process?

A: The following claim types are excluded from the Condition of Payment PA program

  • Veterans Affairs
  • Indian Health Services
  • Medicare Advantage
  • Part A and Part B Demonstrations
Q:Where do we submit the Unique Tracking Number (UTN)?
  • For submission of a paper claim, the UTN should be in Item 23 of the CMS-1500 Claim Form.
  • For electronic claims, the UTN is submitted in either the 2300 - Claim Information loop or 2400 - Service Line loop in the Prior Authorization reference (REF) segment where REF01 = "G1" qualifier and REF02 = UTN.
Q: Can Condition of Payment Prior Authorization Requests by submitted through Electronic Submission of Medical Documentation (esMD)?

A: Yes, when submitting through esMD use the document/content type "8.4".

Q: How to we check the status of a prior authorization request?

A: Status is available on myCGS in the “Claim Preparation” Tab under “Prior Authorization”.


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