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

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

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

End User License Agreement

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Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association website.
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Forms

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.

PA OPD: PA-J15-A-1000

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.

PA Carrots

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.

Facility Info

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.

Request Details

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.

Resubmission Request

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.

Expedited Request

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.

Requestor Information

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.

Beneficiary Information

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.

Attending Physician Information

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.

Service Related Questions

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.

Attachments

Once the form is complete and all documentation attached, select “Submit” to send the PAR to CGS.

Submit

An eSignature box will display. Click OK to confirm the request and to sign the form.

e-Signature

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.

Get Status

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.

Status

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.

Message Inbox