The Centers for Medicare & Medicaid Services (CMS) is implementing a
prior authorization program for certain hospital outpatient department (OPD) services for dates of service (DOS) on or after July 1, 2020. 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.
As a condition of payment for DOS on or after July 1, 2020, a Prior Authorization Request (PAR) is required for the following hospital OPD services:
• Blepharoplasty, eyelid surgery, brow lift, and related services
• Botulinum toxin injections
• Panniculectomy, excision of excess skin and subcutaneous tissue (including lipectomy), and related services
• Rhinoplasty and related services
• Vein ablation and related services
CMS provides a list
of the specific Healthcare Common Procedure Coding System (HCPCS) codes that are included in the OPD Prior Authorization program.
Note: This form should only be submitted if it is determined that a delay could seriously jeopardize the beneficiary’s life, health, or ability to regain maximum function.
Additional PA / OPD information on CMS.gov
SPOT users can upload and submit their OPD PARs through the secure documentation functionality on SPOT. Not a SPOT user? Learn more and register today
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.