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June 15, 2020

Prior Authorization Process and Requirements for Certain Hospital OPD Services: Payment for Related Services

This article was originally published in the June 11, 2020 MLN ConnectsExternal PDF.

Beginning July 1, certain hospital Outpatient Department (OPD) services require prior authorization as a condition of payment. While only the hospital OPD service requires prior authorization, CMS wants to remind other providers that perform services in the hospital OPD setting that claims related to or associated with these services will not be paid if the service requiring prior authorization is not eligible for payment. These related services include, but are not limited to, anesthesiology services, physician services, and facility services. Only associated services performed in the OPD setting are affected.

Depending on the timing of claim submission for any related services, claims may be automatically denied or denied on a postpayment basis.

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