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Prior Authorization

The following table summarizes the key differences between Advance Determination of Medicare Coverage (ADMC) and the Condition of Payment Required Prior Authorization Program for Power Mobility Devices (PMDs).

Topic Brief Description

Advanced Determination of Medicare Coverage (ADMC)

Advance Determination of Medicare Coverage (ADMC) is a voluntary program that allows Suppliers and Beneficiaries to request prior approval of "eligible" items before delivery of the items to the beneficiary. At this time, only customized wheelchairs (manual and power) are eligible for ADMC

Group 2 PRSS Condition of Payment Required Prior Authorization Program

CMS has added the following five HCPCS codes for Group 2 Pressure Reducing Support Surfaces (PRSS) to the Required Prior Authorization List: E0193, E0277, E0371, E0372, and E0373. As of October 21, 2019, prior authorization of these codes is required for all states and territories.

Lower Limb Prosthetics Condition of Payment Prior Authorization

CMS has added the following six HCPCS codes for Lower Limb Prosthetics (LLP) to the Required Prior Authorization list: L5856, L5857, L5858, L5973, L5980, and L5987 (functional level 3 or above). Prior Authorization for LLPs will be implemented in two phases.

Phase 1

Will begin for items furnished on or after May 11, 2020 (Delayed) in one state from each DME MAC jurisdiction: California, Michigan, Pennsylvania, and Texas. CGS will begin accepting requests for Michigan and Texas on April 27, 2020. (Delayed)

Phase 2

Will begin for items furnished on or after October 8, 2020 (Delayed) and expands required prior authorization of these codes to all of the remaining states and territories. CGS will begin accepting PA requests for the remaining states and territories on September 24, 2020. (Delayed)

PMD Condition of Payment Required Prior Authorization Program

All new rental series claims for HCPCS Codes K0813-K0829, K0835-K0843, and K0848-K0864 with a date of delivery on or after July 22, 2019 must be associated with a prior authorization request as a condition of payment. Therefore, lack of a provisionally affirmed prior authorization request will result in a claim denial.

  ADMC Lower Limb Prosthetics Condition of Payment PA Program PMD Condition of Payment PA Program PRSS Condition of Payment PA Program

States

  • Nationwide
  • Phase 1 of required prior authorization will begin May 11, 2020 (Delayed) in one state from each DME MAC jurisdiction: California, Michigan, Pennsylvania, and Texas.
  • Phase 2 will begin October 8, 2020 (Delayed) and expands prior authorization of these codes to all of the remaining states and territories.
  • Nationwide
  • Nationwide

HCPCS Codes

  • K0890, K0891, K0013
  • L5856, L5857, L5858, L5973, L5980, and L5987
  • Required HCPCS: K0813-K0829, K0835-K0843, K0848-K0864
  • E0193, E0277, E0371, E0372, and E0373

Requests Accepted From

  • A beneficiary or a DME supplier
  • A beneficiary or a DME supplier
  • A beneficiary or a DME supplier
  • A beneficiary or a DME supplier

Decisions

  • 30 calendar days
  • Initial and subsequent request: 10 business days
  • Expedited Request: 2 business days
  • Initial Request: 10 business days
  • Subsequent Request: 10 business days
  • Expedited Request: 2 business days
  • Initial Request: 5 business days
  • Subsequent Request:  5 business days
  • Expedited Request: 2 business days

PA Decision Letter Recipients

  • Supplier
  • Supplier
  • Beneficiary or physician, if specifically requested
  • Supplier
  • Beneficiary or physician, if specifically requested
  • Supplier
  • Beneficiary or physician, if specifically requested

Resubmissions

  • One resubmission may be requested in a six-month period
  • Unlimited
  • Unlimited
  • Unlimited

Payments

Voluntary program.

An affirmed ADMC decision means beneficiary meets medical necessity requirements for Medicare

An affirmed ADMC is valid for six months from date of the decision

Any claim eligible for this program must be prior authorized before delivery of the item or it will be denied as prior authorization is a condition of payment
Exclusions: The following claim types are excluded from any PA program described in this operational guide, unless otherwise specified:

  • Veterans Affairs
  • Indian Health Services
  • Medicare Advantage
  • Part A and Part B Demonstrations
  • Claims from Representative Payees for Phase 1 only

Note: Claims from Representative Payees will only be excluded for PA programs that are not implemented on a national level. Before submitting a PAR, suppliers should verify if the beneficiary has a rep payee on file. Once the PA program becomes national, this exclusion will not apply.

Any claim eligible for this program must be prior authorized before delivery of the item or it will be denied as prior authorization is a condition of payment

Any claim eligible for this program must be prior authorized before delivery of the item or it will be denied as prior authorization is a condition of payment

Appeals

ADMC is not eligible for appeal

Standard appeals process applies when claim is denied due to no PAR submitted, in addition to:

  • No GA modifier appended on claim (CO denial)
  • GA modifier is appended and Advance Beneficiary Notice of Noncoverage (ABN) deemed missing or invalid (CO denial)
  • GA modifier is appended and ABN deemed valid (PR denial)

Standard appeals process applies when claim is denied due to no PAR submitted, in addition to:

  • No GA modifier appended on claim (CO denial)
  • GA modifier is appended and Advance Beneficiary Notice of Noncoverage (ABN) deemed missing or invalid (CO denial)
  • GA modifier is appended and ABN deemed valid (PR denial)

Standard appeals process applies when claim is denied due to no PAR submitted, in addition to:

  • No GA modifier appended on claim (CO denial)
  • GA modifier is appended and Advance Beneficiary Notice of Noncoverage (ABN) deemed missing or invalid (CO denial)
  • GA modifier is appended and ABN deemed valid (PR denial)
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