Home ►
Prior authorization ►
Prior authorization program for certain hospital outpatient department services - claim submission guidelines
Last Modified: 4/12/2024
Location: FL, PR, USVI
Business: Part A, Part B
The PA process is a condition of payment. As the term suggests, a condition of payment is a rule, regulation, or requirement that must be met for a provider to lawfully request and receive reimbursement from Medicare.
Once a prior authorization request (PAR) has been submitted and reviewed, the hospital outpatient department and the requestor will receive a decision letter indicating if the PAR has been affirmed, partially affirmed or non-affirmed. The decision letter will contain a unique tracking number (UTN) that is required to be reported on the type of bill (TOB) 13X. The PAR decision and UTN will be valid for a date of service performed within 120 days from the date of the decision.
The UTN included in the decision letter should only be reported on the Part A hospital OPD claim (TOB 13X).
For electronic claims:
• Submit the UTN in the 2300 - Service Line loop in the prior authorization reference (REF) segment:
• REF01 = "G1" qualifier and REF02 = UTN.
• This meets the requirements of the ASC X12 837 technical report 3 (TR3).
For claims submitted in Fiscal Intermediary Standard System (FISS)/Direct Data Entry (DDE):
• Enter UTN in the treatment authorization field on DDE Page 05 (MAP1715).
For paper (UB-04) claims:
• Submit UTN in Form Locator 63.
• Report UTN on the same line (A, B, C) that Medicare is shown in form locator 50 (payer line A, B, C)
• UTN should begin in position 1 of form locator 63
Claims submitted for PARs that received a provisional affirmation PA decision, including any service that was part of a partially affirmed decision, must include the UTN number listed on the decision letter. If all Medicare coverage, coding, and payment requirements are met, the claim will likely be paid. Claims receiving a provisional affirmation may be denied based on either of the following:
• Technical requirements that can only be evaluated after the claim has been submitted for formal processing; or
• Information was not available at the time of a PAR.
• Claims for which there is a provisional affirmation PA decision will be afforded some protection from future audits, both pre- and post-payment; however, review contractors may audit claims if potential fraud, inappropriate utilization, or changes in billing patterns are identified.
Claims submitted for services subject to the required PA without a PA decision and a corresponding UTN will automatically be denied. All appeal rights are then available.
Claims related to or associated with services that require PA as a condition of payment will not be paid, if the service requiring PA is not also paid. 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 post payment basis.
The following claim types are excluded from the PA program:
• Veterans Affairs
• Indian Health Services
• Medicare Advantage
• Part A and Part B Demonstration
• Medicare Advantage sub-category IME only claims
• Part A/B rebilling
• Claims for Emergency Department services when the claim is submitted with modifier ET or revenue code 045X.
• NOTE: This does not exclude these claims from regular medical review.
If the hospital OPD receives a non-affirmed PA decision because the service was determined to be not medically reasonable and necessary, the provider should issue an ABN in advance of performing the service if it is expected that payment will be denied. The provider should submit the claim with the GA modifier appended to it. First Coast will determine the validity of the ABN in accordance with standard ABN polices.
If an applicable claim is submitted without a PA decision and is flagged as having an ABN, it will be stopped for additional documentation to be requested, and a review of the ABN will be performed (to determine the validity of the ABN) following standard claim review guidelines and timelines. or the First Coast
Claims subject to PA requirements under the hospital OPD program follow all current appeals procedures. A PAR that is non-affirmed is not an initial determination on a claim for payment for services provided and, therefore, would not be appealable; however, the provider has an unlimited number of opportunities to resubmit a PAR, provided the claim has not yet been submitted and denied.
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.
.
