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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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March 14, 2023

Power Mobility Device (PMD) Voluntary Accessory Prior Authorization – What Suppliers Need to Know

Outline of the Prior Authorization (PA) Process for Suppliers:

Supplier receives the order and medical records from the face-to-face encounter for a PMD base on the Required Prior Authorization List and the order and medical records to substantiate the voluntary accessories
Supplier submits the Prior Authorization Request (PAR) and required medical records for the PMD base and the accessories to the DME MAC for review.
The DME MAC sends a decision letter and Unique Tracking Number (UTN) to the supplier.
If the supplier receives a provisional affirmative PA decision, the supplier
- Delivers the PMD and accessories within 6 months, then
- Submits the claim (including the UTN on the claim)
If the supplier receives a non-affirmative PA decision, the supplier
- Obtains additional documentation and resubmits the PAR; or
- Submits claim for denial (including the UTN on the claim)

Which PMD base codes can the accessories be submitted for?

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

Which PMD accessory codes can be submitted for voluntary prior authorization?

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

CMS has selected 53 PMD accessories that are eligible for voluntary prior authorization. The list of codes are located at: voluntary-prior-authorization-list.pdf (cms.gov) or use the JB: Prior Authorization Lookup Tool or JC: Prior Authorization Lookup Tool

Do the accessories need to be submitted on the same request as the PMD base?

Yes. The prior authorization request for the accessories must be submitted on the same request as the required prior authorization base.

What is the timeframe for delivery of the PMD and voluntary accessories under the prior authorization process?

Suppliers must deliver the PMD and accessories which has received an affirmative determination within 6 months following the determination.

What are the review timelines for the PMD and voluntary accessories prior authorization request (PAR)?

The DME MACs will complete their review of the initial and resubmitted PAR and send a detailed decision letter postmarked or faxed by the 10th business day following the DME MAC's receipt of the PAR.

Does the DME MAC review for same or similar items as part of the PAR process?

Yes, the DME MAC will check if the patient has previously received a same or similar piece of equipment, and if so, whether the item has reached its reasonable useful lifetime (RUL) as part of the PAR.

Do the PMD accessories need to be submitted on the same claim as the PMD base?

Yes, the accessories should be submitted on the same claim as the base.

Where do we submit the Unique Tracking Number (UTN)?

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.

Can prior authorization requests be submitted through Electronic Submission of Medical Documentation (esMD)?

Yes, when submitting through esMD, use the document/content type "8.4."

How do we check the status of a prior authorization request?

The status is available on myCGS in the "Claim Preparation" tab under "Prior Authorization." Instructions are available in the DME myCGS User Manual.

What happens when the PMD base prior authorization is affirmed without a PAR for accessories?

The claim for the PMD base item would be allowed in accordance with existing procedures. The claim for an accessory would go through the normal claims review process.

What happens when the PMD base prior authorization is affirmed, and some accessories are affirmed, and some accessories are non-affirmed?

The claim for the base would be allowed in accordance with existing procedures. The claim for the provisionally affirmed accessories would be allowed, and the claim for the non-affirmed accessories would be denied.

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Power Mobility Device (PMD) Voluntary Accessory Prior Authorization – What Suppliers Need to Know

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