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.
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Prior Authorization Process

CGS will review the information submitted with a prior authorization request (PAR), issue a decision (affirmative or non-affirmative), and assign a Unique Tracking Number (UTN). See details below.

OPD Services (HCPCS Codes)

See the Final List of Outpatient Services That Require Prior Authorization .

Prior authorization is a condition of payment. Claims submitted for services rendered without a provisional affirmation PAR decision may receive a denial.

Request Types & Timeframes

When submitting a PAR, select the appropriate request type and allow the allotted timeframe for CGS to issue a decision.

Request Type

Description

Review Decision Timeframe

Initial

First PAR submission for this beneficiary/date of service.

NOTE: A PAR is valid for one claim/date of service.

7 calendar days

Resubmission

Any subsequent PAR submission (i.e., to correct an error or omission after receiving a non-affirmation decision for an initial PAR). Providers have an unlimited number of opportunities to resubmit a PAR.

NOTE: Report the most recent UTN with each resubmission request.

7 calendar days

Expedited

Used ONLY when a delay for a decision could seriously jeopardize the beneficiary's life, health or ability to regain maximum function.

NOTE: Don't select this request type based solely on the scheduled procedure date. When appropriate, you must include the specific reason/rationale for CGS to substantiate the need for an expedited decision.

2 business days

Decision Letter(s)

CGS will send a decision letter with the UTN to:

The requester (via the same method used to submit the PAR)
A fax number provided in the PAR (optional)
The beneficiary

NOTE: While the prior authorization process applies to hospital OPDs, CMS allows a physician or practitioner to submit a PAR on the hospital OPD's behalf. The requester is responsible for communicating the decision/UTN to the appropriate provider(s).

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 a future claim submitted to Medicare for the requested service does not likely meet Medicare's coverage, coding and payment requirements.

NOTE: CGS will provide an explanation for a non-affirmative decision. You may submit a resubmission request with additional/updated documentation until you receive a provisional affirmation decision.

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.

How to Submit a Prior Authorization Request

Who is Responsible?

The prior authorization process applies to, and is a condition of payment for, hospital OPDs. CMS allows a physician or practitioner to submit a PAR on the hospital OPD's behalf. The requester is responsible for communicating the decision/UTN to the appropriate provider(s).

When to Submit?

Submit a PAR before you furnish the service and submit a claim to Medicare. In addition, please plan and allow the allotted timeframe for a decision (7 calendar days for initial/resubmission requests or 2 business days for expedited requests).

NOTE: A PAR is valid for one claim/date of service.

What to Submit?

CMS doesn't require a specific form. To help ensure you include all required data elements, and to avoid a rejection or processing delays, we recommend using the following:

myCGS portal
NOTE: This option is only available when you sign in with a user ID registered to a Part A NPI/PTAN.
OPD Prior Authorization Request Forms
NOTE: Access the form from our website for each request. Don't save forms to your computer for future use.

Also include medical record documentation to support that the service is medically reasonable and necessary and meets all applicable Medicare coverage, coding and payment rules.

How to Submit?

Use one of these methods to submit a PAR:

myCGS portal (preferred method)
Electronic Submission of Medical Documentation (esMD)
Fax or mail (to the number/address on the PAR form)

Claim Submission

Unique Tracking Number (UTN)

Report the UTN on the Part A hospital OPD (TOB 13X) claim only.

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.

Affirmed PA Decision on File

If the UTN reported on a claim corresponds with a provisional affirmation decision, including any service(s) that was part of a partially affirmed decision, the claim:

Will likely pay if all Medicare coverage, coding and payment requirements are met.
May deny based on either of the following:
- Technical requirements that are only evaluated after claim submission
- Information not available at the time of the PAR
Is 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.

Non-Affirmed PA Decision on File

If the UTN reported on a claim corresponds with a non-affirmation decision, including any non-affirmed service(s) that was part of a partially affirmed decision:

The claim will deny.
All appeal rights are then available.
NOTE: The prior authorization process is a condition of payment. As the term suggests, a rule, regulation, or requirement must apply for a provider to lawfully request and receive reimbursement from Medicare.
You may then submit the claim to secondary insurance, if applicable.

No PA Decision on File

Claims for a service that requires prior authorization without a UTN:

Will automatically deny.
All appeal rights are then available.
NOTE: The prior authorization process is a condition of payment. As the term suggests, a rule, regulation, or requirement must apply for a provider to lawfully request and receive reimbursement from Medicare.
If a HCPCS code that requires prior authorization is reported with modifier GA (Advance Beneficiary Notice of Noncoverage (ABN) issued), the claim will suspend, and the provider will receive an Additional Documentation Request (ADR) letter. Upon receipt of the requested documentation, CGS will perform a review to determine the validity of the ABN. See the standard claim review guidelines and timelines outlined in the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 30, § 40.

Denials for Related Services

Related services include, but aren't limited to, associated anesthesiology, physician, and/or facility services performed in the OPD setting. See Appendix B – OPD PA Part B Associated Codes List.

Claims for related or associated services may automatically deny, or deny on a postpayment basis, when OPD services that require prior authorization as a condition of payment receive a non-affirmation decision and/or claim denial.

Claim Exclusions

Claim types excluded from the prior authorization program include:

Veterans' Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage IME only claims
Part A/B Rebilling
Emergency Department services (claims submitted with modifier ET or revenue code 045X)
- NOTE: This doesn't exclude these claims from regular medical review.

Appeals

Claims subject to prior authorization requirements under the hospital OPD program follow all current appeals procedures. A non-affirmed PAR decision isn't appealable since it's not an initial determination on a claim for payment for services provided. Providers have an unlimited number of opportunities to resubmit a PAR before submitting a claim.

A non-affirmation decision doesn't prevent the provider from submitting a claim. Submission of such a claim and resulting denial does 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 rule, regulation, or requirement must apply for a provider to lawfully request and receive reimbursement from Medicare.

See the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 29 for additional information.

Updated: 12.31.2024