March 19, 2020 - Revised: November 10, 2020
Lower Limb Prosthetics (LLP) Prior Authorization – What Suppliers Need to Know
Q: Which LLP Codes are subject to prior authorization?
A: L5856, L5857, L5858, L5973, L5980, and L5987 (functional level is 3 or above)
Q: When will prior authorization be required?
A: Prior Authorization for LLPs will be implemented in two phases.
- Phase 1 began September 1, 2020 in California, Michigan, Pennsylvania, and Texas.
- Phase 2 will begin December 1, 2020 and expands prior authorization of these codes to all of the remaining states and territories.
Q: When will CGS begin to accept prior authorization requests?
A: CGS began accepting prior authorization requests for phase 1 on August 18, 2020 for beneficiaries residing in Michigan and Texas.
The DME MACs will accept prior authorization requests for phase 2 on or after November 17, 2020 for all of the remaining states and U.S. territories.
Q: What are the review timelines for a 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 10th business day of receipt of the PAR.
Expedited Requests: If the DME MAC substantiates the need for an expedited decision, the DME MAC will make reasonable efforts to communicate a decision within 2 business days of receipt of the expedited request. For expedited review requests, suppliers should use fax, esMD, or the MAC Portal (when available) to avoid delays with mailing.
Q: Are there any exceptions to the Condition of Payment Prior Authorization process?
A: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
Note: Claims from Representative Payees are only excluded for PA programs that are not implemented on a national level (Phase 1). 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.
Q: Where do we submit the Unique Tracking Number (UTN)?
A: 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: When a Prior Authorization Request is submitted for 2 of the affected codes, such as foot and a knee, must 2 separate requests be submitted? If so how are 2 UTNs submitted on a claim?
A: No. Two separate requests are not required. However, if there are two codes that require prior authorization on the same request, there will be two separate UTNs and two response letters, one for each required prior authorization code. When the claim is submitted electronically, each UTN must be entered on the 2400 - Service Line for the applicable HCPCs code.
Q: Can Condition of Payment Prior Authorization Requests be submitted through Electronic Submission of Medical Documentation (esMD)?
A: Yes, when submitting through esMD use the document/content type "8.4".
Q: Can Condition of Payment Prior Authorization Requests be submitted through myCGS?
A: Yes. Additional information is located at: https://www.cgsmedicare.com select the applicable jurisdiction then myCGS in the top left of the page.
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". Prior authorization requests can also be submitted through myCGS.