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July 28, 2020

Required Prior Authorization for Certain DMEPOS Items to Resume

Due to the importance of medical review activities to the Centers for Medicare & Medicaid Services (CMS) program integrity efforts, effective August 3, 2020, CMS will discontinue exercising enforcement discretion and resume the requirement to prior authorize certain Power Mobility Devices (PMDs) and Pressure Reducing Support Surfaces (PRSS).

For Prior Authorization (PA) requests and claims prior to August 3, DME MACs will continue to accept and review voluntary PA requests for HCPCS codes on the Required Prior Authorization List. Suppliers are reminded they must continue to use the CR modifier for all HCPCS codes billed and enter "COVID-19" in the NTE 2400 (line note) or NTE 2300 (claim note) segments of the American National Standard Institute (ANSI X12) format or field 498-PP of the National Council for Prescription Drug Program (NCPDP) format for claims associated with a non-affirmation decision or claims submitted without requesting PA that would normally cause a payment denial. These abbreviations may also be used in Item 19 of the CMS-1500 claim form. These instructions must be applied to all subsequent rental months to ensure payment.

Additionally, the implementation of PA for Lower Limb Prostheses HCPCS codes: L5856, L5857, L5858, L5973, L5980 and L5987 will begin for dates of service on or after September 1, 2020 in the states of California, Michigan, Pennsylvania, and Texas. Suppliers may begin submitting PA requests August 18, 2020 in anticipation of delivering the item on or after September 1, 2020.

Reopenings

For claims denied due to the COVID-19 Public Health Emergency (PHE) associated with PA submissions on or after March 01, 2020 until August 2, 2020, suppliers may request a reopening of their claim by contacting their MAC.

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