Prior Authorization ProcessCGS will review the information submitted with the PAR, issue a decision (affirmative or non-affirmative) and assign a Unique Tracking Number (UTN). Request Types and TimeframesWhen 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.
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). DecisionsA 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.
How to Submit a Prior Authorization RequestWho 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. 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. 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.
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. How/Where Should a PAR Be Submitted?A PAR may be submitted using one of the following methods:
Claim SubmissionUnique Tracking Number (UTN)The UTN included in the decision letter should only be reported on the Part A hospital OPD (TOB 13X) claim.
Affirmed PA Decision on FileIf 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:
Non-Affirmed PA Decision on FileIf 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:
No PA Decision on FileIf a UTN is not reported on a claim for a service that requires prior authorization:
Denials for Related ServicesClaims 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. Claim ExclusionsThe following claim types are excluded from the PA program:
AppealsClaims 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. OPD Services/HCPCS Codes |