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Prior authorization (PA) program for certain hospital outpatient department (OPD) services - submitting the prior authorization request (PAR)
Last Modified: 4/12/2024
Location: FL, PR, USVI
Business: Part A, Part B
The hospital OPD provider must submit the
PAR 
to First Coast before the service is provided to the beneficiary and before the claim is submitted for processing. The PAR must include all documentation necessary to show that the service meets applicable Medicare coverage, coding, and payment rules.
The requester, or the person or entity that submits the PAR, documentation, and /or claims, must include the data elements below in all PARs to avoid potential delays in processing of the initial submission documents.
• Beneficiary first and last name
• Medicare Beneficiary Identifier (MBI)
• Beneficiary Gender
• Beneficiary Date of Birth
• Facility name
• CMS Certification Number (CCN)
• Facility address
• Facility National Provider Identifier (NPI)
• Physician/Practitioner’s Name
• Physician/Practitioner’s NPI
• Physician/Practitioner CMS Certification Number (CCN)
• Physician/Practitioner’s Address
• Provider Phone Number
• Provider Fax Number
• Requestor Name
• Requestor Phone Number
• Requestor Fax Number/Email address
• Requester signature (print and sign) and date
• Anticipated Date of service
• Healthcare Common Procedure Coding System (HCPCS) Code(s)
• Paired Code(s) for Botulinum Toxin Injections
• Diagnosis Code(s) (providers who submit using electronic submission of medical documentation (esMD) must include a diagnosis code(s))
• Start Date of the Authorization
• State (location) of Authorization
• Units of Service
• In addition to the required PAR documentation in the Initial Submission section, the resubmission of the PAR should contain an exact match of the beneficiary's first name, last name, date of birth to the previous submission, and the Unique Tracking Number (UTN) associated with the previous submission.
Requesters have the following options for submitting PARs to First Coast:
1. Mail
2. Fax
3. esMD (content type 8.5)
First Coast Service Options, Inc.
JN Prior Authorization
PO Box 3033
Mechanicsburg, PA 17055-1804
Fax#: 1-855-815-3065
Phone #: 1-855-340-5975 (Prior Auth Customer Service)
esMD: indicate document/content type “8.5”
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 Service Options will make reasonable efforts to communicate a decision within two business days of receipt an accepted expedited request.
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.
