Ambulatory Surgical Center Prior Authorization Claim Submission Guidelines
Prior authorization (PA) under the Ambulatory Surgical Center (ASC) Prior Authorization Demonstration is voluntary. However, if a provider elects to bypass PA, applicable ASC claims will be subject to prepayment medical review.
Once a prior authorization request (PAR) is submitted and reviewed, the ASC will receive a decision letter indicating if the PAR is affirmed, partially affirmed, or non-affirmed. The decision letter will contain a unique tracking number (UTN) that is required to be reported on the ASC facility place of service (POS) 24 claim. The PAR decision and UTN will be valid for a date of service performed within 120 days from the date of the decision.
Reporting the UTN on the Claim
The UTN is required to be reported on the ASC facility POS 24 claim.
Report the UTN from the decision letter which is valid for 120 days from the date listed as follows on the ASC claim:
- Electronic claim in 2300 - Service Line loop in the Prior Authorization reference (REF) segment:
- REF01 = G1 qualifier
- REF02 = UTN
- CMS-1500 claim form in Item 23 in the first 14 positions
Example of Reporting POS and UTN on the ASC Facility Claim:
Claims Submitted With an Affirmed Decision on File
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 postpayment; however, review contractors may audit claims if potential fraud, inappropriate utilization, or changes in billing patterns are identified.
Claims Submitted with a Non-Affirmed Decision on File
A non-affirmed PAR decision is not an initial claim determination and is not appealable. However, a non-affirmation PAR decision does not prevent claim from being submitted. Remember a provider has an unlimited number of opportunities to resubmit a PAR if a claim has not yet been submitted and denied.
If a provider submits a claim for a non-affirmed PAR, the UTN from the decision letter must be reported on the claim. Novitas will deny claims submitted when the PA decision was non-affirmed. The claim denial is appealable.
If a service receives a non-affirmed PA decision and a claim is submitted with the GA modifier, the medical records from the PA request will not be used during the Additional Documentation Request (ADR) process. The records must be resubmitted in response to the ADR, including a copy of the signed Advanced Beneficiary Notice (ABN).
For more information on Appeals visit the CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 29 or the First Coast Appeals Center.
No PA Decision on File - Prepayment Reviews
ASC claims submitted without a PA decision on file will be subject to a prepayment medical review. Prepayment medical record review means that the Novitas will make a claim determination before claim payment using the standard Medicare prepayment medical record review process.
ASCs do not need to do anything differently when submitting a claim without a UTN. They do not need to put any information in the remarks field or submit any unsolicited documentation at the time of claim submission.
First Coast will stop the claim prior to payment and send the ASC an additional documentation request (ADR):
- Letter is sent through the US Postal Service and/or electronically
- ASCs will have 45 days to respond to the ADR with all requested documentation through:
- SPOT portal
- Fax
- esMD (for more information see: www.cms.gov/esMD)
If an ASC claim is selected for prepayment review and an ADR is issued, the requested documentation should be submitted through the Submit Prepay ADR Response option under Prior Auth in SPOT.
For step-by-step instructions, refer to the Submit Prepay ADR Response section in the SPOT User Guide, Section 9 - Prior Auth. This option should be used to respond to ADRs associated with ASC prepayment reviews when no prior authorization decision is on file.
When responding to an ADR, include a copy of the ADR cover sheet and all submitting documentation. Do not use any other cover sheets. A copy of the ADR cover sheet is not necessary for submissions using SPOT, the claim number from the letter is entered in the request. If submitting the response through the SPOT portal, documentation is submitted using the Submit Prepay ADR Response feature under the Prior Auth option. First Coast will have 30 days to review the documentation and render a claim determination:
- If approved, claim will process for payment.
- If not-approved, claim will denial and will have appeal rights.
Claims for Associated and Related Services
Associated or related professional services, including anesthesiology and physician services, are not subject to PA. Therefore, ASC facility providers should report only the procedure code(s) subject to PA on the PAR and should not include anesthesia CPT codes. As part of this demonstration, ASC facility providers must report the UTN on their claims, while other billing providers and practitioners, including anesthesia providers, should submit their claims as usual and should not report a UTN.
Although anesthesia and other associated or related professional services do not require PA, payment for these services is dependent on the payment eligibility of the ASC service. As a result, if there is a non-affirmation PAR decision for the ASC service(s), or if the ASC facility claim is denied following prepayment review, claims for associated or related services, including anesthesiology and physician services, will also be denied and will not be paid if the ASC service subject to PA or prepayment review is not eligible for payment.
Claim Exclusions
The following claim types are excluded from the ASC PA demonstration:
- Veterans Affairs
- Indian Health Services
- Medicare Advantage
- Medicare Advantage sub-category IME only claims
- Railroad Retirement Board
Advanced Beneficiary Notice (ABN)
If the ASC receives a non-affirmed PA decision because the service was determined to be not medically reasonable and necessary, the provider should issue an advanced beneficiary notice (ABN) before performing the service if payment is expected to be denied. The claim should be submitted with the GA modifier appended. Novitas will determine the validity of the ABN in accordance with standard ABN policies.
If a claim is submitted without a PA decision and includes the GA modifier (waiver of liability statement issued as required by payer policy), the claim will be stopped for an additional documentation request (ADR). The provider must submit supporting documentation, including a copy of the signed ABN, as records submitted during the PAR process are not used for the ADR review. The ABN will be reviewed for validity in accordance with standard claim review guidelines and timelines.
The provider should issue an ABN and submit the claim with a GX modifier (notice of liability issued, voluntary under payer policy) if Medicare is expected to deny payment for a service under the statutory exclusion for purely cosmetic services. In these circumstances, an ABN is voluntary and is not required to bill the patient for a service denied under the cosmetic services exclusion. However, CMS encourages providers to issue an ABN to inform beneficiaries of their potential financial liability.
For more information, review the CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 30, section 40 or the First Coast Advance Beneficiary Notice of Non-Coverage Article.
Medicare Secondary Situations
If the provider is seeking payment from Medicare as a secondary payer for an applicable ASC service, PA should be obtained. If all relevant Medicare coverage requirements are met for the item(s), then a provisional affirmative PA decision will be sent to the provider.
In situations where Medicare is the secondary payer, the provider will need to submit the claim to the primary insurance before submitting the claim to Medicare as secondary. The provider or beneficiary must include the UTN on the claim submitted to Medicare for payment or the claim will be stopped for prepayment review.
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