skip to content
Thank you for visiting First Coast Service Options' Medicare provider website. This website is intended exclusively for Medicare providers and health care industry professionals to find the latest Medicare news and information affecting the provider community.
To enable us to present you with customized content that focuses on your area of interest, please select your preferences below:
Select which best describes you:
Select your location:
Select your line of business:

By clicking Continue below you agree to the following:

LICENSE FOR USE OF "PHYSICIAN'S CURRENT PROCEDURAL TERMINOLOGY" (CPT), FOURTH EDITION End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2022 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:
Local Coverage Determinations (LCDs),
Local Medical Review Policies (LMRPs),
Bulletins/Newsletters,
Program Memoranda and Billing Instructions,
Coverage and Coding Policies,
Program Integrity Bulletins and Information,
Educational/Training Materials,
Special mailings,
Fee Schedules;

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 and Medicaid Services (CMS), formerly known as Health Care Financing Administration (HCFA). 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. Applicable FARS/DFARS restrictions apply to government use.

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. 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 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.

AMA - U.S. Government Rights

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.

ADA CURRENT DENTAL TERMINOLOGY, (CDT)
End User/Point and Click Agreement: These materials contain Current Dental Terminology (CDTTM), Copyright © 2016 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING ON THE BUTTON LABELED "ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK ON THE BUTTON LABELED "DECLINE" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT 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 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. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the ADA website.

Applicable Federal Acquisition Regulation Clauses (FARS)\Department of restrictions apply to Government Use.

ADA DISCLAIMER OF WARRANTIES AND LIABILITIES: CDT 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. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly 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 to you if you violate the terms of this Agreement. The ADA is a third party beneficiary to this Agreement.

CMS DISCLAIMER: The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. 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 CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. 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.

End Disclaimer


This website provides information and news about the Medicare program for health care professionals only. All communication and issues regarding your Medicare benefits are handled directly by Medicare and not through this website. For the most comprehensive experience, we encourage you to visit Medicare.gov or call 1-800-MEDICARE. In the event your provider fails to submit your Medicare claim, please view these resources for claim assistance.
Join eNews       En Español
Text Size:
YouTube LinkedIn Email Print
Send a link to this page
[Multiple email addresses must be separated by a semicolon.]
Last Modified: 11/19/2024 Location: FL, PR, USVI Business: Part A, Part B

Prior authorization program for certain hospital outpatient department services

Background

CMS implemented a nationwide prior authorization program in July 2020 for certain hospital outpatient department (OPD) services, with additional services added in July 2021 and July 2023. CMS believes prior authorization for certain hospital OPD services will ensure that Medicare beneficiaries continue to receive medically necessary care while protecting the Medicare Trust Fund from improper payments and keeping the medical necessity documentation requirements unchanged for providers.

Education on related services

Overall, as a condition of payment, a prior authorization request (PAR) is required for the hospital OPD services listed below. Click on the available links to learn more about these services.
Blepharoplasty, eyelid surgery, brow lift, and related services
Rhinoplasty and related services
Effective for dates of service (DOS) beginning July 1, 2023, CMS has added a new service category to the Hospital OPD PA program. This additional hospital OPD service category will require prior authorization as a condition of payment for facet joint interventions.
CMS provides a list external pdf file of the specific HCPCS codes that are included in the OPD prior authorization program.
Note: Since CMS has mandated prior authorization for these particular hospital OPD services as a condition of payment, when a prior authorization request (PAR) is received and it has been determined that the related procedure has already been rendered, the PAR will be non-affirmed.

Submissions

Note: This form is available for submission through the SPOT. If you do not have a SPOT account, learn how to register.
Reminder: Stay timely with your PAR submissions – View timeliness details
Expedited requests
The requester can submit an expedited review of the PAR if it is determined that a delay could seriously jeopardize the beneficiary’s life, health, or ability to regain maximum function. However, if medical documentation does not support an expedited process, the request will be subject to the normal timeframe. First Coast will make reasonable efforts to communicate a decision within two business days of receipt an accepted expedited request.

Quick links

General information

Question
Answer
WHO
Hospital OPD when rendering certain OPD services for Medicare beneficiaries that bill Medicare Part A on a type of bill (TOB) 13X can receive prior authorization.
WHAT
The hospital OPD (also known as the requestor) will be responsible to submit a prior authorization request (PAR) and all documentation for certain hospital outpatient services and their related services before the services are provided to Medicare beneficiaries and before the provider can submit claims for payment under Medicare for these services.
WHEN
Effective for DOS on or after July 1, 2020, the prior authorization applies to the following hospital OPD services: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation.
Effective for DOS on or after July 1, 2021, the prior authorization applies to the following hospital OPD services: cervical fusion with disc removal and implanted spinal neurostimulators.
Effective for DOS on or after July 1, 2023, the prior authorization applies to the following hospital OPD services: facet joint interventions.
WHERE
The program applies to all jurisdictions nationwide.
WHY
CMS believes PA for certain hospital OPD services will ensure that Medicare beneficiaries continue to receive medically necessary care while protecting the Medicare Trust Fund from improper payments and keeping the medical necessity documentation requirements unchanged for providers.
It is designed to ensure all relevant coverage, coding, payment rules, and medical record(s) requirements are met before the service is rendered to the beneficiary and the claim is submitted for payment.
HOW
Submit the PAR and all documentation. A unique tracking number (UTN) will be assigned with each PAR. An initial decision letter will be issued within 10 business days of receipt of initial request. Resubmission notifications will be issued within 10 business days of receipt of the resubmission request.
Note: Effective for PARs received January 1, 2025, and after the decision letter will be issued within 7 calendar days.

Upcoming events

Please visit our educational events calendar for all currently available training opportunities.

Documentation

To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for services.
For more information on coverage and documentation requirements, refer to:

Dates of Service
Local Coverage Determination (LCD)/LCA/NCD
Type of Service
For services performed on or after July 11, 2021
panniculectomy and rhinoplasty
For services performed on or after July 11, 2021
panniculectomy and rhinoplasty
For services performed on or after March 21, 2021
blepharoplasty
For services performed on or after March 21, 2021
blepharoplasty
For services performed on or after March 21, 2021
botulinum toxins
For services performed on and after March 21, 2021
botulinum toxins
For services performed on or after December 27, 2020
vein ablation
For services performed on or after March 11, 2021
vein ablation
National Coverage Determination (NCD) 160.7
implanted spinal neurostimulators
For services performed on or after October 1, 2015
facet joint interventions
Revision effective date: January 1, 2023
facet joint interventions
For services performed on or after August 11, 2024
cervical fusion
For services performed on or after August 11, 2024
cervical fusion

PA contact information

Prior authorization customer service phone number: 1-855-340-5975
Fax number: 1-855-815-3065
Mailing address:
First Coast Service Options, Inc.
JN Prior Authorization
PO Box 3033
Mechanicsburg, PA 17055-1804
Priority mailing address:
First Coast Service Options, Inc.
Attention: JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg, PA 17050
View additional information regarding overall prior authorization initiatives.
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.