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Prior authorization

Modified: 11/13/2024
Effective for dates of service July 1, 2021, and after, hospital outpatient department (HOPD) providers will need to obtain prior authorization (PA) for cervical fusion with disc removal if performed in a HOPD setting and billed with the follow CPT codes: 22551 and 22552.
Modified: 10/31/2024
The following document was developed based on questions and answers posed during our webinars on the prior authorization (PA) program for certain hospital outpatient department (OPD) services.
Modified: 10/4/2024
CMS implemented a prior authorization program for repetitive scheduled non-emergency ambulance transport for dates of service on or after April 1, 2022.
Modified: 8/8/2024
CMS has removed CPT codes 64492 and 64495 from the listing of codes requiring prior authorization. View our article to learn more about these changes.
Modified: 8/8/2024
Facet joint interventions may be used in pain management for chronic cervical/thoracic and lumbar/sacral pain arising from the paravertebral facet joints. Imaging guidance (fluoroscopy or CT per code descriptor) is used to assure accurate placement of the needle for the injection. Paravertebral facet joint denervation is a therapeutic intervention used to provide both long-term pain relief and reduce the likelihood of recurrence of chronic cervical/thoracic or lumbar/sacral pain confirmed as originating in the facet joint’s medial branch nerve.
Modified: 8/8/2024
To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for services.
Modified: 7/18/2024
CMS implemented a prior authorization program for certain hospital outpatient department services for dates of service on or after July 1, 2020.
Modified: 6/28/2024
Use this calculator to determine the time remaining to perform the approved procedure before the authorization expires.
Modified: 5/10/2024
A repetitive service is defined as medically necessary ambulance transportation that is furnished three or more times during a 10-day period OR at least once per week for at least three weeks. Repetitive ambulance services are often needed by beneficiaries receiving dialysis or cancer treatment.
Modified: 5/3/2024
Botulinum toxins are potent neuromuscular blocking agents that are useful in treating various focal muscle spastic disorders and excessive muscle contractions, such as dystonia, spasms, and twitches.
Modified: 5/3/2024
The following are tips and reminders that will assist providers in avoiding a delay or dismissal of a Prior Authorization Request.
Modified: 4/26/2024
Prior authorization is a process through which coverage is determined prior to providing or billing the service. This process allows the provider to submit documentation prior to providing or billing the service. The contractor will then alert the submitter of any potential issues with the submitted information.
Modified: 4/26/2024
CMS is releasing results from the first year of the Non-Emergent Hyperbaric Oxygen (HBO) Therapy Prior Authorization model. [CR9940]
Modified: 4/25/2024
Physician certification statements (PCS) are required for patients who are under the direct care of a physician and are required to verify the medical necessity for certain scheduled and unscheduled non-emergency ambulance transports. Read this article to learn more.
Modified: 4/19/2024
View this prior authorization request coversheet for repetitive, scheduled non-emergent ambulance transport (RSNAT).
Modified: 4/19/2024
Are you sending hardcopy mail to submit your requests to First Coast? Did you know there are faster and easier ways to send your requests to us? Avoid the wait. Learn about the electronic options available for you to submit prior authorization requests.
Modified: 4/16/2024
CMS is implementing a prior authorization program for certain hospital outpatient department services for dates of service on or after July 1, 2020. Review the fax coversheet needed for submission.
Modified: 4/12/2024
First Coast sent letters to providers announcing the expansion of the repetitive, scheduled, non-emergent ambulance transport (RSNAT) in jurisdiction J (JN) effective April 1, 2022.
Modified: 4/12/2024
View these submission guidelines when submitting prior authorization requests for certain hospital outpatient department services
Modified: 4/12/2024
Expedited prior authorization request hospital outpatient procedures Medicare Part A Fax/Mail Coversheet - Allowable if it is determined that a delay could seriously jeopardize the beneficiary’s life, health, or ability to regain maximum function.
Modified: 4/12/2024
Repetitive, scheduled non-emergent ambulance transport (RSNAT) has been effective as of April 1, 2022. Through this program, a unique tracking number (UTN) is issued for each medical decision provided – whether affirmed or non-affirmed. When submitting corresponding claims, this UTN should be placed in the UTN# field.
Modified: 4/12/2024
Claims submitted for a prior authorization request (PAR) that received a provisional affirmation PA decision, including any service that was part of a partially affirmed decision, must include the 14-byte unique tracking number (UTN) number listed on the decision letter. The hospital OPD claim is reported on a type of bill 13X. If all Medicare coverage, coding, and payment requirements are met, the claim will likely be paid.
Modified: 4/12/2024
The PA team has been receiving and processing prior authorization requests (PAR) for certain hospital OPD services. View the following reminders prior to submitting your request
Modified: 4/12/2024
The repetitive scheduled non-emergent ambulance transport (RSNAT) prior authorization request submission checklist helps you identify all required elements on the prior authorization request (PAR) are included with your submission.
Modified: 4/7/2024
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) expands the repetitive scheduled non-emergent ambulance transport prior authorization model to all states if the program meets certain requirements. [CR9940]
Modified: 4/5/2024
To submit a prior authorization request, complete the prior authorization coversheet. Failure to populate every field could result in delays in processing your request, a non-affirmed decision, or a determination that the request is incomplete and cannot be processed.
Modified: 4/5/2024
Follow this instructions to learn how to file a claim once you received the unique tracking number (UTN) related to the prior authorization of repetitive, scheduled non-emergency ambulance transports.
Modified: 3/29/2024
Vein ablation and related services; some patients may want varicose vein treatment for cosmetic reasons. Medicare does not cover cosmetic surgery or expenses incurred in connection with such surgery.
Modified: 3/25/2024
This article is designed to assist medical providers with documenting the beneficiary’s medical condition supporting coverage for non-emergent ambulance transportation.
Modified: 3/25/2024
The following article provides a list of common terms used by the medical review department for prior authorization requests.
Modified: 3/22/2024
Review this checklist to learn about the documentation requirements for medical professionals related to the repetitive, scheduled, non-emergency prior authorization program.
Modified: 3/22/2024
Review these FAQs to learn more about the prior authorization for repetitive scheduled non-emergency ambulance transport.
Modified: 3/15/2024
Hospital outpatient departments (OPDs) who demonstrate compliance with Medicare coverage, coding, and payment rules related to prior authorization (PA) may be eligible for exemption. This exemption would remain in effect for a 12-month period or until CMS elects to withdraw the exemption.
Modified: 3/15/2024
CMS covers the implantation of central nervous system stimulators as a therapy for the relief of chronic intractable pain.
Modified: 3/15/2024
Learn how to complete the the prior authorization request (PAR) coversheet for repetitive scheduled non-emergency ambulance transports.
Modified: 3/15/2024
Prior Authorization Request Hospital Outpatient Procedures Medicare Part A Fax/Mail Coversheet
Modified: 3/8/2024
When submitting a prior authorization request (PAR), be mindful of specific guidelines relating to proper submission to avoid potential non-affirmations. Review this article to avoid non-affirmations.
Modified: 3/1/2024
Review this checklist to learn about the documentation requirements to ensure an affirmed decision on your prior authorization request (PAR) for repetitive, scheduled, non-emergency transport.
Modified: 3/1/2024
When submitting prior authorization requests, be aware of response timeframes and documentation guidelines.
When submitting prior authorization requests, be aware of response timeframes and documentation guidelines.
Modified: 2/23/2024
Effective for dates of service July 1, 2020, and after, hospital outpatient department (HOPD) providers will need to obtain prior authorization (PA) for panniculectomy, excision of excess skin and subcutaneous tissue (including lipectomy), and related services if performed in a HOPD and billed with the following CPT codes.
Modified: 2/21/2024
Are you participating in prior authorization and want to know how to maintain exemption within this program? Do you have questions regarding the different timeframes and dates relating to the deadlines and requirements associated with prior authorization exemption? This new video was created to address exactly those questions.
Modified: 2/16/2024
CMS has implemented the prior authorization program for certain repetitive, scheduled non-emergent ambulance transports in Florida, Puerto Rico and the US Virgin Islands. Learn more about the program and how you can participate.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.