Prior Authorization (PA) for Certain Hospital Outpatient Department (OPD) Services (Part A)
CMS implemented a prior authorization process for certain services provided in the outpatient department of the hospital. This process requires OPDs to submit requests for provisional affirmation of coverage to be reviewed BEFORE the applicable services is furnished. PA requests may be submitted through myCGS and is available to users registered as Part A providers.
NOTE: This is a Part A requirement. Users registered under Part B do not have access to this form.
Once logged into myCGS, select the FORMS tab.
- Under the “Select a Topic” drop-down box, click “Prior Authorization.”
- The “Select a Type” drop-down will default to “PA OPD.”
- Select the “PA OPD: PA-J15-A-1000” link at the bottom of the page.
Once the PA form loads you will find several sections requiring your attention. Carrots at the top corners of each section allow you to collapse or expand the sections.
Facility Information
This section will auto-populate with information specific to your myCGS ID and provider information. No changes can be made to the Provider Information section.
Request Details
Select whether this is an initial or resubmission request.
- Initial Request: The first prior authorization request (PAR) sent to us for review and decision.
- We will review attached medical records and send an initial decision letter that is either postmarked or faxed within 10 business days following the receipt of the initial request.
- Resubmission Request: Subsequent PAR resubmissions to correct an error or omission identified after a PA decision has been made by CGS.
- Resubmissions include additional/updated documentation after the initial PAR was non-affirmed. We will postmark or fax notification of the decision of these resubmitted requests to the provider or beneficiary (if specifically requested by the beneficiary) within 10 business days of receipt of the resubmission request.
- When a resubmission is requested, you must enter the 14-digit unique tracking number (UTN) assigned to the initial/previous PAR. Click the “Get Previous Submission Information” so that details from the previous decision will display. Verify the UTN entered is correct and specific to your provider.
- Expedited Request: You may submit a request for an expedited review of a PAR if delays in receipt of a PA decision could jeopardize the life or health of the beneficiary. Enter the reason and details for the expedited PA decision. Upon receipt, a decision will be made within 2 business days.
Requestor Information
This section identifies your name, email, and phone number associated with your myCGS user ID and will auto-populate. If you would like to receive your PAR decision via fax, check the box and enter the fax number of the hospital OPD.
Beneficiary Information
Enter the beneficiary’s Medicare Beneficiary Identifier (MBI), name, date of birth, and gender. When submitting initial requests, you must click the “Validate Beneficiary” button. This will allow myCGS to check eligibility records to ensure the beneficiary information entered is correct.
NOTE: Be sure to verify the information is correct by referring to the beneficiary’s Medicare card.
Attending Physician Information
Enter the name, National Provider Identifier (NPI), and complete address of the physician/non-physician practitioner (NPP) who has overall responsibility for the patient’s medical care and treatment. If the attending physician would like to receive a copy of the PA decision letter, enter the physician’s fax number to the form.
Services Requested
The “Services Requested” section of the form varies depending upon the type of service for the PAR.
- On the “Select a Service” drop-down, click on the service for which the PAR is for. Depending on the service selected, certain fields will display.
- HCPCS Code: Select the CPT code from the listing
- Primary Diagnosis Code: Enter the primary diagnosis code
- Number of Units: Enter the number of units (for Botulinum Toxin Injection PARs)
- Secondary Diagnosis Code: Identify a second diagnosis code, if applicable
- Related Codes: Enter any CPT/HCPCS codes related to those selected above
- Dates of Service: Enter the date the service will be rendered
- Type of Bill: Identify the appropriate TOB applicable to this service
- Part A hospital outpatient (TOB 13X)
- Service Related Questions will display based upon the type of service. Answers to these questions help support medical necessity.
Attachments
Documentation from the medical record to support medical necessity of the service is to be attached to the myCGS form. Attachments must be in a PDF format and no large than 40MBs. The total of all attachments cannot exceed 150MBs.
NOTE: You must attach at least one document. Please refer to the applicable Local Coverage Determination and/or Local Coverage Article for direction.
Once the form is complete and all documentation attached, select “Submit” to send the PAR to CGS.
An eSignature box will display. Click OK to confirm the request and to sign the form.
NOTE: If you do not click OK to sign the form, it will not be sent.
Confirmation
Confirmation messages will be delivered to your Messages inbox. The message that includes a Submission ID may be used to check the status of the PAR by entering the Submission ID into the "Get Status" screen located on any tab throughout the portal.
- PAR statuses available:
- Confirmed: The PAR has been received and successfully uploaded into our system.
- Decision: A decision has been made on the PAR. Refer to the PAR Decision Letter for affirmed/non-affirmed details.
View PAR Decision Letter
The decision letters for PARs submitted through myCGS will be delivered to your myCGS Messages inbox (unless you request to receive it via Fax in the Requestor Information section above.) You may also check the Prior Auth folder for decision letters.
The decision letter will open as a PDF document.
NOTE: PAR decisions and UTNs are valid for 120 days (the decision date is counted as day 1).