March 4, 2024
Prior Authorization for Beneficiaries with Retroactive Medicare Coverage
The Prior Authorization Smart Submission (PASS) in the myCGS web portal makes it easy to show that the item has already been delivered because of retroactive Fee-for-Service (FFS) Medicare coverage:
- Select “Yes” on the PASS Delivery Confirmation screen when the item(s) has already been delivered.
- Answer the next question: Is the beneficiary eligible for retroactive Medicare coverage?
- “Yes” and proceed through the submission process.
- “No” will prompt the following alert: “A Prior Authorization is not needed for this item since it has already been delivered and the beneficiary is not eligible for retroactive Medicare coverage.”
Example:
The supplier delivered a power mobility device coded K0813 on December 10, 2023 to a patient who was not enrolled in FFS Medicare at the time.
On February 20, 2024, the beneficiary enrolled in FFS Medicare and the coverage start date was retroactive to November 1, 2023.
Before you submit a claim:
- Send a prior authorization request:
- Include a statement that the item was already delivered, and Medicare coverage is retroactive.
- Include all necessary documentation to support the medical necessity.
- Select “Yes” on the myCGS Delivery Confirmation screens.
- Receive a Unique Tracking Number (UTN).
Refer to the DME myCGS User Manual for additional instructions on how to use Prior Authorization Smart Submission (PASS). See the Prior Authorization page for information about the Prior Authorization process.
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