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Prior Authorization

Prior Authorization

Medicare requires that all HCPCS codes that appear on the Required Prior Authorization ListExternal pdf must be submitted for prior authorization before delivery and claim submission. Refer to the Prior Authorization Process for DMEPOS Operational GuideExternal pdf for complete information and instructions. You can also use the Prior Authorization Lookup Tool to enter any HCPCS code and quickly determine if prior authorization is required or voluntary.

The fastest, easiest way to submit prior authorization requests is through the DME myCGS portal.

Aside from the myCGS web portal, suppliers can submit PA requests via mailing address, fax, and esMD using the Prior Authorization (PA) Request CoversheetPDF. Submitting this coversheet gives you faster processing times, increased accuracy, organized submissions, and a lower risk of rejection. Place the Prior Authorization Request Coversheet first, before all other documentation.

Prior Authorization Additional Resources

HCPCS Codes

Lower Limb Prosthetics (LLP)

L5856, L5857, L5858, L5973, L5980, L5987

Orthoses

L0648, L0650, L1832, L1833, L1851

Power Mobility Device (PMD)

K0800-K0802, K0806-K0808, K0813-K0829, K0835-K0843, K0848-K0864.

Power Mobility Device (PMD) Accessories - Voluntary

E0950, E0955, E1002-E1010, E1012, E1029, E1030, E2310-E2313, E2321-E2330, E2351, E2373, E2377, E2601-E2608, E2611-E2616, E2620-E2625, K0020, and K0195

Pressure Reducing Support Surfaces (PRSS)

E0193, E0277, E0371, E0372, E0373



Prior Authorization and Advanced Determination of Medicare Coverage

 

ADMC

LLP

Orthoses

PMD

PMD Accessories - Voluntary

PRSS

States

Nationwide

Nationwide (Since December 1, 2020)

Nationwide (Since October 10, 2022)

Nationwide

Nationwide (Since April 6, 2023)

Nationwide (Since October 21, 2019)

HCPCS

E1161, E1231-E1234, K0005, K0008, K0009, K0890, K0891, K0013

L5856, L5857, L5858, L5973, L5980, L5987

L0648, L0650, L1832, L1833, L1851

K0800-K0802, K0806-K0808, K0813-K0829, K0835-K0843, and K0848-K0864.

E0950, E0955, E1002-E1010, E1012, E1029, E1030, E2310-E2313, E2321-E2330, E2351, E2373, E2377, E2601-E2608, E2611-E2616, E2620-E2625, K0020, and K0195

E0193, E0277, E0371, E0372, E0373

Requests Accepted From

Beneficiary or supplier

Beneficiary or supplier

Beneficiary or supplier

Beneficiary or supplier

Beneficiary or supplier

Beneficiary or supplier

Decisions

30 calendar days

10 business days

Expedited: 2 business days

5 business days

Expedited: 2 business days

10 business days

Expedited: 2 business days

10 business days

Expedited: 2 business days

5 business days

Expedited: 2 business days

Letter Recipients

Supplier and beneficiary

Supplier and beneficiary or physician, if specifically requested

Supplier and beneficiary or physician, if specifically requested

Supplier and beneficiary or physician, if specifically requested

Supplier and beneficiary or physician, if specifically requested

Supplier and beneficiary or physician, if specifically requested

Delivery Timeframes

The delivery must be within 6 months following the determination.

PAR decisions for these codes will remain valid for one hundred and twenty (120) calendar days following the provisional affirmation review decision.

PAR decisions for these codes will remain valid for sixty (60) calendar days following the provisional affirmation review decision.

PAR decisions for these codes will remain valid for six months following the "affirmed" review decision.

PAR decisions for these codes will remain valid for six months following the "affirmed" review decision.

PAR decisions for these codes will remain valid for one month following the "affirmed" review decision.

Resubmissions

One resubmission in a 6-month period

Unlimited

Unlimited

Unlimited

Unlimited

Unlimited

Payments

Voluntary program

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

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, unless an acute or competitive bidding program exception applies.

Exclusions: The following claim types are excluded from any PA program described in the operational guide, unless otherwise specified:

    • Veterans Affairs
    • Indian Health Services
    • Medicare Advantage
    • Part A and Part B Demonstrations

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

Voluntary program

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

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)

Standard appeals process applies once a claim is denied

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)

Revised: 08.04.23

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