Prior Authorization Timelines for HOPD Services
Prior authorization is a condition of payment. Claims submitted for services rendered without a prior authorization in place may receive a denial.
Types of Prior Authorizations Timelines
There are 3 types of prior authorization requests:
- Initial
- Resubmission
- Expedited (initial or resubmission)
Initial and resubmission requests require up to 7 calendar days for review.
Expedited requests require 2 business days for review. Documentation must demonstrate that any delays could jeopardize the beneficiary's life and overall health. If not, we will review the request within 7 calendar days.
When you submit a prior authorization request, be sure to allow enough time for CGS to complete the review within the allotted timeframe. Also, account for weekends or holidays (not included as business days) and non-affirm decisions (to address any issues and resubmit the request). If a request is for a date of service that is less than 7 calendar days from the submission date, we can't guarantee a decision in time for the service.
Reasons for Potential Rejections/Non-Affirmed Decisions
- Incomplete, incorrect, or conflicting information on the request form
- No anticipated procedure date on the request form
- Anticipated date of service is less than 7 calendar days from the submission date
- Example: Prior authorization request submission date is July 5th; requested date of service is July 10th.
- Request submitted on the same day as the requested date of service
- Request submitted with the next day as the requested date of service
- Request submitted after providing the service
- Illegible request form
Tips & Recommendations
- Verify the procedure date and submit your request in time for CGS to review it within the required timeframe.
- Allow enough time for resubmission(s) in case you receive a non-affirmed decision.
- Review the documentation requirements and resources related to the HOPD service requested before submitting your prior authorization request.
- Ensure you use the current request form. For each request, access the form on our website, type the information, choose the drop-down selections, and print. Do not save or download the form for a future request.
- Handwritten forms need to be legible.
- Review the completed request form to ensure all information is accurate.
- Make sure the request form includes the appropriate HCPCS codes that require prior authorization.
Resubmission Process
When resubmitting a prior authorization request after a non-affirmed decision:
- Complete a new prior authorization request form and indicate "resubmission" in the Request Type field.
- Type or write the most recent non-affirmed UTN number in the UTN field. The UTN number appears in the non-affirmed notification letter.
- Gather ALL documentation for the request, including:
- Documentation submitted with the prior request.
- New/additional documentation to support the service requested.
- Submit the resubmission request with ALL documentation mentioned above (also applies to myCGS portal submissions). Be sure to allow 7 calendar days for review.
*If you received a rejection notification with no UTN, follow the initial submission process.
Resources
Send questions to: j15apriorautheducation@cgsadmin.com.
Updated: 12.31.2024