SHARE PRIOR AUTHORIZATION FEEDBACK
OPD Prior Authorization
The Centers for Medicare & Medicaid Services (CMS) established a nationwide prior authorization (PA) process as a condition of payment for certain hospital outpatient department (OPD) services. Effective for dates of service July 1, 2020, Part A hospital OPDs must submit a prior authorization request (PAR) and supporting documentation to their Medicare Administrative Contractor (MAC) and receive a decision before rendering the service and submitting a claim for processing.
Click on an item below to learn more about that topic:
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OPD Services/HCPCS Codes
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How to Submit a Prior Authorization Request
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Medical Record Documentation
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Authorization Process
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Exemption Process
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Claim Submission
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Appeals
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CGS Resources
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CMS Resources
OPD Services/HCPCS Codes
How to Submit a Prior Authorization Request
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Who is Responsible for Submitting a PAR?
The OPD PA process applies to Part A hospital OPDs that submit claims with Type of Bill (TOB) 13X and are paid under the Outpatient Prospective Payment System (OPPS). Since the PA process is a condition of payment for the hospital service(s), the Part A hospital OPD is responsible for ensuring that a PAR is submitted.
NOTE: Although other providers, such as a physician/staff may submit a PAR on the hospital OPD's behalf, departmental collaboration is crucial. Please reference the Authorization Process section below for additional information.
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When Should a PAR Be Submitted?
A PAR must be submitted prior to rendering the service and submitting a claim for processing. In addition, please plan and allow the allotted timeframe for a decision (10 business days for initial/resubmission requests or 2 business days for expedited requests). Please reference the Authorization Process section below for additional information.
NOTE: A PAR is valid for one claim/date of service.
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What Must Be Submitted?
CMS does not require a specific form to request prior authorization; however, completing the request in myCGS or by utilizing the CGS service-specific PAR form(s) will help to ensure all required data elements are included and avoid any rejections and/or delays in processing.
- Using myCGS to Obtain Prior Authorization (PA) for Certain Hospital Outpatient Department (OPD) Services
NOTE: This program applies to Part A hospital OPDs; therefore, the PAR forms may only be accessed when a user ID associated with a Part A NPI/PTAN is used to sign in to the myCGS portal. - OPD Prior Authorization Forms
NOTE: We encourage you to access the most recent form available on the CGS website for each request. The most common reason for rejection is due to submission of an old form and/or handwritten requests.
In addition, any medical record documentation to support that the service was medically reasonable and necessary and meets all applicable Medicare coverage, coding and payment rules is required. Please reference the Medical Record Documentation section below for additional information.
- Using myCGS to Obtain Prior Authorization (PA) for Certain Hospital Outpatient Department (OPD) Services
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How/Where Should a PAR Be Submitted?
A PAR may be submitted using one of the following methods:
- myCGS Portal (preferred method)
- Electronic Submission of Medical Documentation (esMD)
- FAX (to the CGS FAX number indicated at the bottom of the PAR form)
- Mail (to the CGS address indicated at the bottom of the PAR form)
Medical Record Documentation
To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for the service(s). General documentation requirements for each service that requires prior authorization are listed below. In addition, providers should reference any CGS Local Coverage Determination (LCD) / Local Coverage Article (LCA), where applicable. In the absence of an LCD/LCA, CGS utilizes CMS-based regulatory guidance, National Coverage Determinations (NCDs), evidence-based specialty guidelines and accepted standards of care, and high level, high quality published literature to establish medical necessity
NOTE: CGS is not able to accept any of the following in place of medical record documentation: a physician letter of medical necessity, written comments of medical necessity within the PAR, documentation that does not contain medical credentials, or generic statements.
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Blepharoplasty
General Documentation Requirements for Blepharoplasty, Eyelid Surgery, Brow Lift and Related Services
- Documented excessive upper/lower lid skin
- Supporting pre-op photos
- Signed clinical notes support a decrease in peripheral vision and/or upper field vision
- Signed physician's or non-physician practitioner recommendations
- Documented subjective patient complaints which justify functional surgery (vision, ptosis, etc.)
- Visual field studies exams (when applicable)
Coverage Criteria
- Local Coverage Determination (LCD): Blepharoplasty (L33944)
- Local Coverage Article: Billing and Coding: Blepharoplasty (A56439)
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Botulinum Toxin Injections
NOTE: Use of Botulinum Toxin codes (J0585, J0586, J0587 or J0588) in conjunction/paired with a procedure code other than 64612 or 64615 will not require prior authorization under this program.
General Documentation Requirements for Botulinum Toxin Injections
- Support for the medical necessity of the botulinum toxin (type A or type B) injection
- A covered diagnosis
- Dosage and frequency of planned injections
- Support for the medical necessity of electromyography procedure performed in conjunction with botulinum toxin type A injections to determine the proper injection site(s) (when applicable)
- Support of the clinical effectiveness of the injections (for continuous treatment)
- Specific site(s) injected
- For support of management of a chronic migraine diagnosis, the medical record must include a history of migraine and experiencing frequent headaches on most days of the month
- A statement that traditional methods of treatments such as medication, physical therapy, and other appropriate methods have been tried and proven unsuccessful (when applicable)
Coverage Criteria
- Local Coverage Determination (LCD): Botulinum Toxins (L33949)
- Local Coverage Article: Billing and Coding: Botulinum Toxins (A56472)
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Panniculectomy
General Documentation Requirements for Panniculectomy, Excision Skin and Subcutaneous Tissue (Including Lipectomy) and Related Services
- Stable weight loss with BMI less than 35 be obtained prior to authorization of coverage for panniculectomy surgery (when applicable)
- Description of the pannus and the underlying skin
- Description of conservative treatment undertaken and its results
- The medical record document(s) that the panniculus causes chronic intertrigo or candidiasis or tissue necrosis that consistently recurs over three months and is unresponsive to oral or topical medication (when applicable)
- Pre-op photograph (if requested)
- Copies of consultations (when applicable)
- Related operative report(s) (when applicable)
- Any other pertinent information
Coverage Criteria and Resources for Determining Medical Necessity
- CMS OPD Operational Guide
- CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 3, § 3.6.2.2 and 3.10
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 16, § 10, 20 and 120
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, § 40.6(A)
- Social Security Act § 1862(a)(1)(A)
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Rhinoplasty
General Documentation Requirements for Rhinoplasty and Related Services
- Medical documentation, with evaluation and management, supporting medical necessity of the service that is to be performed
- Radiologic imaging if done
- Photographs that document the nasal deformity (if applicable)
- Documentation supporting unresponsiveness to conservative medical management (if applicable)
Coverage Criteria and Resources for Determining Medical Necessity
- CMS OPD Operational Guide
- CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 3, § 3.6.2.2 and 3.10
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 16, § 10, 20 and 120
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, § 40.6(A)
- Social Security Act § 1862(a)(1)(A)
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Vein Ablation
General Documentation Requirements for Vein Ablation and Related Services
- Doppler ultrasound
- Documentation stating the presence or absence of deep vein thrombosis (DVT), aneurysm, and/or tortuosity (when applicable)
- Documented incompetence of the valves of the saphenous, perforator or deep venous systems consistent with the patient's symptoms and findings (when applicable)
- Photographs if the clinical documentation received is inconclusive
- The patient's medical record must contain a history and physical examination supporting the diagnosis of symptomatic varicose veins (evaluation and complaint), and the failure of an adequate (at least 3 months) trial of conservative management (before the initial procedure)
Coverage Criteria
- Local Coverage Determination (LCD): Varicose Veins of the Lower Extremity, Treatment of (L34082)
- Local Coverage Article: Billing and Coding: Varicose Veins of the Lower Extremity, Treatment of (A57305)
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Cervical Fusion with Disc Removal
General Documentation Requirements for Cervical Fusion with Disc Removal
- Condition requiring procedure
- Physical examination
- Duration/character/location/radiation of pain
- Activity of daily living (ADL) limitations
- Imaging reports pertinent to performed procedure
- Operative report(s) (when applicable)
- Conservative treatment modalities include but are not limited to:
- Physical Therapy
- Occupational Therapy
- Injections
- Medications
- Assistive device use
- Activity modification
Coverage Criteria and Resources for Determining Medical Necessity
- CMS OPD Operational Guide
- CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 3, § 3.6.2.2 and 3.10
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 16, § 10, 20 and 120
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, § 40.6(A)
- Social Security Act § 1862(a)(1)(A)
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Implanted Spinal Neurostimulators
Providers who plan to perform both the trial and permanent implantation procedures using CPT 63650 in the hospital OPD will only be required to submit a PAR for the trial procedure. To avoid a claim denial, providers must place the Unique Tracking Number (UTN) received for the trial procedure on the claim submitted for the permanent implantation procedure. When the trial is rendered in a setting other than a hospital OPD, providers will need to request PA for CPT 63650 as part of the permanent implantation procedure in the hospital OPD.
NOTE: CPT codes 63685 (Insertion or replacement of spinal neurostimulator pulse generator or receiver) and 63688 (Revision or removal of implanted spinal neurostimulator pulse generator or receiver) were temporarily removed from the list of OPD services that require prior authorization, as finalized in CMS-1736-FC.
General Documentation Requirements for trial or permanent Implanted Spinal Neurostimulators
- Indicate if this request is for a trial or permanent placement
- Physician office notes including:
- Condition requiring procedure
- Physical examination
- Treatments tried and failed including but are not limited to:
- Spine surgery
- Physical Therapy
- Medications
- Injections
- Psychological therapy
- Documentation of appropriate psychological evaluation
- For permanent placement, include all of the above documentation, as well as documentation of pain relief with the temporary implanted electrode(s).
- A successful trial should be associated with at least 50% reduction of target pain or 50% reduction of analgesic medications.
Services associated with devices approved under an Investigational Device Exemption (IDE) study must undergo prior authorization and meet the coverage requirements in NCD 160.7.
Coverage Criteria and Resources for Determining Medical Necessity
- CMS OPD Operational Guide
- CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 3, § 3.6.2.2 and 3.10
- CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 16, § 10, 20 and 120
- CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 12, § 40.6(A)
- Social Security Act § 1862(a)(1)(A)
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Authorization Process
CGS will review the information submitted with the PAR, issue a decision (affirmative or non-affirmative) and assign a Unique Tracking Number (UTN).
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Request Types and Timeframes
When submitting a PAR, it is important to select the appropriate request type and allow the allotted timeframe for CGS to issue a decision as outlined below.
Request Type Description Review Decision Timeframe Initial First PAR submitted for this beneficiary/date of service
NOTE: A PAR is valid for one claim/date of service.
10 business days Resubmission Any subsequent PAR submitted to correct an error or omission after the initial PAR was non-affirmed. A provider may resubmit a PAR an unlimited number of times.
NOTE: Ensure the most recent UTN is reported with each resubmission request.
10 business days Expedited A request for a PAR decision to be performed on an accelerated timeframe because delays in review and response could jeopardize the life or health of the beneficiary ONLY.
NOTE: Do not select this request type based solely on the scheduled date of service for a procedure. The specific reason/rationale must be included for CGS to substantiate the need for an expedited decision.
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Decision Letter(s)
CGS will send a decision letter with the UTN to the requester using the method the PAR was received. CGS also has the option to send a copy of the decision letter via FAX if a valid FAX number is provided with the PAR (even if the PAR was submitted via a method other than FAX). A copy of the decision letter will also be sent to the beneficiary.
NOTE: While the OPD PA process is a condition of payment for the Part A hospital OPD service(s), a PAR may be submitted by other providers, such as a physician/staff on behalf of the hospital OPD. The requester is responsible for ensuring the decision/UTN is communicated to the appropriate provider(s). Inquiries related to a PAR status/decision cannot be addressed via the Provider Contact Center (PCC) or the Medical Review department.
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Decisions
A valid PAR will result in one of the following decisions. A PAR decision/UTN is valid for 120 days from the date of the decision letter.
Decision Description
Provisional Affirmation A preliminary finding that a future claim submitted to Medicare for the service(s) likely meets Medicare's coverage, coding and payment requirements
Non-Affirmation A preliminary finding that if a future claim is submitted to Medicare, the requested service does not likely meet Medicare's coverage, coding and payment requirements
NOTE: CGS will provide detailed information about all missing and/or non-compliant information that resulted in the non-affirmative decision. A resubmission request may be submitted with additional/updated documentation an unlimited number of times until a provisional affirmation decision is received.
Provisional Partial Affirmation One or more service(s) on the PAR received a provisional affirmation decision and one or more service(s) received a non-affirmation decision
Exemption Process
Hospital OPDs who submit PARs will be assessed on a semi-annual basis and those who demonstrate compliance with Medicare coverage, coding, and payment rules related to the prior authorization program are eligible for exemption.
Exemption Timeline
Annual Cycle (January 1 – September 30) |
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October 1st - MACs calculate the affirmation rate of initial prior authorization requests (PARs) sent January 1st, and after. Exempt providers will be notified of an affirmation rate greater than 90%. |
November 2nd - Exempt providers receive 60 days’ notice prior to the beginning of the exemption cycle. |
November 30th - Exempt providers who wish to opt-out of the emption process must submit opt-out request by November 30th |
January 1st - The exemption cycle begins. Exempt providers should not submit prior authorization requests. |
August 1st - Exempt providers will receive an additional documentation request for a 10-claim sample from the period such providers were exempt to determine continued compliance. |
November 2nd (On or before) - Providers will receive a notice of withdrawal from exemption if applicable. Providers with less than a 90% claim approval rate during the post payment 10-claim review will be withdrawn and returned to the standard PA cycle. |
December 18th - Providers who did not meet the 90% claim approval rate will no longer be exempt and are required to submit prior authorizations. |
December 18th - Providers who are no longer exempt must have an associated Prior Authorization for any claim submitted on or after December 18th. Providers who achieved 90% or greater claim approval rate during post payment review are notified of continued exemption effective December 18th. |
* Hospital OPDs have 45 days to respond to the ADR and CGS will complete the review within 45 days of receipt of the requested documentation. Additional documentation submitted after the initial 45-day response timeframe will not change the provider compliance rate if CGS has already finalized it and sent notification. CGS will still review late documentation, issue a determination, and make a claim adjustment, if necessary. Claim denials are subject to the normal appeals process; however, overturned appeals will not change the OPD's exemption status.
Additional information is available in the Exemption Article.
Claim Submission
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Unique Tracking Number (UTN)
The UTN included in the decision letter should only be reported on the Part A hospital OPD (TOB 13X) claim.
- For electronic claims, report the UTN in positions 1–18 of the Treatment Authorization Field (loop 2300 REF02 (REF01=G1) segment).
- For all other submissions, TAB to the second Treatment Authorization Field and key the UTN.
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Affirmed PA Decision on File
If the UTN reported on a claim is associated with a provisional affirmation decision, including any service(s) that was part of a partially affirmed decision:
- The claim will likely be paid if all Medicare coverage, coding and payment requirements are met.
- The claim may be denied based on either of the following:
- Technical requirements that can only be evaluated after the claim has been submitted for formal processing
- Information not available at the time of the PAR
- The claim will be afforded some protection from future audits (pre- and postpayment); however, review contractors may audit claims if potential fraud, inappropriate utilization or changes in billing patterns are identified.
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Non-Affirmed PA Decision on File
If the UTN reported on a claim is associated with a non-affirmation decision, including any non-affirmed service(s) that was part of a partially affirmed decision:
- The claim will be denied.
- All appeal rights are then available.
NOTE: The prior authorization process is a condition of payment. As the term suggests, a condition of payment is a rule, regulation, or requirement that must be met in order for a provider to lawfully request and receive reimbursement from Medicare. - The claim may then be submitted to secondary insurance, if applicable.
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No PA Decision on File
If a UTN is not reported on a claim for a service that requires prior authorization:
- The claim will be automatically denied.
- All appeal rights are then available.
NOTE: The prior authorization process is a condition of payment. As the term suggests, a condition of payment is a rule, regulation, or requirement that must be met in order for a provider to lawfully request and receive reimbursement from Medicare. - If a HCPCS code that requires PA is reported with modifier GA (Advance Beneficiary Notice of Noncoverage (ABN) issued), the claim will suspend and an Additional Documentation Request (ADR) letter will be sent to the provider. CGS will perform a review to determine the validity of the ABN following standard claim review guidelines and timelines outlined in the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 30, § 40.
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Denials for Related Services
Claims related to or associated with services that require PA as a condition of payment will not be paid, if the service requiring PA is not also paid. These related services include, but are not limited to, services such as anesthesiology services, physician services, and/or facility services. Only associated services performed in the OPD setting will be affected.
Depending on the timing of claim submission for any related services, claims may be automatically denied or denied on a postpayment basis.
The OPD PA Part B Associated Codes List is located in Appendix B of the CMS OPD Operational Guide.
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Claim Exclusions
The following claim types are excluded from the PA program:
- Veterans' Affairs
- Indian Health Services
- Medicare Advantage
- Part A and Part B Demonstration
- Medicare Advantage IME only claims
- Part A/B Rebilling
- Claims for Emergency Department services when the claim is submitted with modifier ET or revenue code 045X.
- NOTE: This does not exclude these claims from regular medical review.
Appeals
Claims subject to PA requirements under the hospital OPD program follow all current appeals procedures. A PAR that is non-affirmed is not an initial determination on a claim for payment for services provided and, therefore, would not be appealable; however, the provider has an unlimited number of opportunities to resubmit a PAR, provided the claim has not yet been submitted and denied.
A non-affirmation PA decision does not prevent the provider from submitting a claim. Submission of such a claim and resulting denial would constitute an initial payment determination, which makes the appeal rights available.
NOTE: The prior authorization process is a condition of payment. As the term suggests, a condition of payment is a rule, regulation, or requirement that must be met in order for a provider to lawfully request and receive reimbursement from Medicare.
For additional information, please reference the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 29.