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Last Modified: 12/6/2024 Location: FL, PR, USVI Business: Part A, Part B

Instructions for completing the prior authorization request (PAR) cover sheet for hospital outpatient department (OPD) services

To submit a prior authorization request for hospital outpatient department services, complete the prior authorization request (PAR) cover sheet pdf file.
Failure to populate every field listed below could result in delays in processing your request, a non-affirmed decision, or a determination that the request is incomplete and cannot be processed.

Field

Description

Beneficiary Last Name
Enter the beneficiary’s full last name, to include Jr. or Sr. as appropriate.
Beneficiary First Name
Enter the beneficiary’s full first name.
MEDICARE ID
Enter the beneficiary’s Medicare Beneficiary Identifier (MBI).
Gender
Check either Male or Female.
Date of Birth
Enter the beneficiary’s date of birth (DOB) in MM/DD/YYYY format.
Facility NPI
Enter the hospital outpatient department's 10-digit National Provider Identifier (NPI).
Facility CCN/PTAN
Enter the hospital outpatient department's 6-digit CMS certification number (CCN). This is sometimes referred to as the Provider Transaction Access Number (PTAN).
Facility Fax Number
Enter the hospital outpatient department's fax number. This will enable the HOPD to receive the prior authorization decision letter.
Facility Name and Address
Enter the hospital outpatient department's full name and street address, city, state, and ZIP code.
Physician NPI
Enter the performing physician's 10-digit NPI.
Physician PTAN
Enter the performing physician's 6-digit Medicare certification number (sometimes referred to as the PTAN).
Physician Fax Number
Enter the performing physician's fax number. This will enable the performing physician to receive a copy of the prior authorization decision letter.
Physician Name and Address
Enter the performing physician's full name and street address, city, state, and ZIP code.
Requestor Name
Enter the full name of the individual submitting the prior authorization fax/mail coversheet and required medical records.
Requestor Email Address
Enter the requestor's email address.
Requestor Phone Number
Enter the 10-digit telephone number (XXX-XXX-XXXX) of the individual who can be contacted for questions regarding the prior authorization fax/mail coversheet and medical records.
Alternative Phone Number and/or Direct Extension
Enter an alternate 10-digit telephone number (XXX-XXX-XXXX) or extension where we can reach to the requestor, if necessary.
Procedure Code(s)
Enter the procedure code for the outpatient service requiring the PA. Refer to the CMS list external pdf file of the specific Healthcare Common Procedure Coding System (HCPCS) codes that are included in the OPD PA program.
Modifier
Select the appropriate modifier either RT, LT or 50.
Site(s)/Level(s)
Enter the site/level, as applicable for the requested outpatient department services.
Units of Service
Enter the number of units being requested.
Request Type
Select whether is an initial submission or a resubmission.
Diagnosis Codes (esMD submission only)
Enter the diagnosis codes for the conditions necessitating the hospital outpatient department services.
Providers who submit using esMD must include diagnosis code(s).
Anticipated Date of Service
Enter the date for the anticipated date of service.
State (location) of Authorization
Enter the state based on where the hospital outpatient department is located.
Date Submitted
Provide the date the coversheet was completed/submitted in MM/DD/YYYY format.
Comments
Please enter Previous Non-Affirm UTN for Resubmission requests, Change in Facility, Record updates or reasons for Expedited review. Any additional information applicable to assist with medical review.
Note: Do not use the expedited prior authorization request coversheet pdf file unless the normal timeframe for a decision notification could jeopardize the life or health of the beneficiary. If the medical records submitted with the expedited request do not justify an expedited request, then the request will be subject to the normal process and timeframes.
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