Ambulatory surgical center (ASC) prior authorization request (PAR) submission guidelines
The ASC or the requester on behalf of the ASC, submits the PAR before the service is provided to the beneficiary and before the claim is submitted for processing; otherwise, the claim will be subject to prepayment review. The PAR will not be accepted after the service has been completed. The PAR must include all necessary documentation to show that the service meets applicable Medicare coverage, coding, and payment rules.
To submit a PAR, complete the Prior authorization request ambulatory surgical center (ASC) procedures Medicare Part B fax/mail coversheet and follow the instructions for completing the coversheet. The PAR must include necessary documentation from the medical record to support the service is reasonable and necessary and any other relevant documents as deemed necessary by First Coast. Refer to relevant local coverage determinations (LCDs) and national coverage determinations (NCDs), as appropriate.
The requester, or the person or entity that submits the PAR, documentation, and/or claims, must include the data elements below in all PARs. 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. List only the procedure codes on the list of ASC services for prior authorization on the PAR. Providers can use the Prior Authorization Code Lookup Tool to verify if a code is subject to ASC PA.
Note: Additional, optional elements may be requested for submission of the PAR.
PAR fax/mail coversheet elements and instructions
Complete all fields as appropriate on the fax/mail coversheet for data elements listed and attach supporting medical documentation. Complete one fax/mail coversheet for each PAR for which documentation is being submitted.
| 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). |
| Date of birth | Enter the beneficiary’s date of birth (DOB) in MM/DD/YYYY format. |
| ASC facility NPI | Enter the ASC's 10-digit NPI. |
| ASC facility CCN/PTAN | Enter the ASC's 6-digit PTAN. This is sometimes referred to as the CMS certification number (CCN). The PTAN is issued by the MAC and the CCN is issued by CMS. The PTAN may/may not be different than the CCN. ASCs use the PTAN for billing purposes. |
| ASC facility fax number | Enter the ASC's fax number. This will enable the ASC to receive the PAR decision letter. |
| ASC facility name and address | Enter the ASC'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 PAR 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 PA fax/mail cover sheet 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 PA fax/mail cover sheet and medical records. |
| Requestor fax number | Enter a 10-digit fax number (XXX-XXX-XXXX). This will enable the requestor to receive a copy of the PAR decision letter. |
| Request type | Select using the dropdown if this is an initial submission or a resubmission of a previously non-affirmed prior authorization request. |
| Procedure code | Enter the procedure code for the ASC service subject to PA. Refer to the CMS List of Ambulatory Surgical Center Services for Prior Authorization. |
| Modifier | Select the modifier either RT or LT when appropriate. |
| Site(s)/Level(s) | Enter the site/level, as applicable for the requested ASC service(s) subject to PA. |
| Unit(s) of service | Enter the number of units being requested for the procedure code. |
| Diagnosis code(s) (esMD submission only) | Enter the diagnosis codes for the conditions necessitating the service being provided in the ASC. Providers who submit using esMD must include diagnosis code(s). |
| Anticipated DOS | Enter the date for the anticipated date of service for the procedure. |
| State (location) of authorization | Enter the state based on where the ASC facility is located. |
| Date submitted | Provide the date the cover sheet was completed/submitted in MM/DD/YYY format. |
| Comments | Please enter previous non-affirm UTN for resubmission requests, change in facility, record updates for resubmissions, reason for expedited request, etc. Any additional information applicable to assist with PA review. |
Submitting the PAR
Requesters have the following options for submitting PARs to First Coast:
- SPOT (Secure provider online tool)
- The PAR coversheet is built into the portal. Complete fields as required and upload supporting documentation.
- Mail:
First Coast Service Options, Inc.
JN Prior Authorization
P.O. Box 3033
Mechanicsburg, PA 17055-1804
- Fax: 1-855-815-3065
- esMD (content type 8.7):
- For more information about esMD, see http://www.cms.gov/esMD
PAR review and decisions
First Coast will review the information submitted and the decision will be issued to the requestor listed on the PAR.
The decision that can result from the PAR review include the following:
- Provisional affirmation decision - a preliminary finding that a future claim submitted to Medicare for the service likely meets Medicare's coverage, coding, and payment requirements.
- Non-affirmation decision - a preliminary finding that if a future claim is submitted for the service, it does not meet Medicare's coverage, coding, and payment requirements.
- Provisional partial affirmation decision - means that one or more service(s) on the request received a provisional affirmation decision, and one or more service(s) received a non-affirmation decision.
First Coast will send a written copy via mail and a fax copy of the decision letter to the requestor listed on the PAR. If applicable, detailed reasons for the non-affirmation will be included. The decision letter will be sent to the requestor using the method the PAR was received.
- If the requestor included a fax number on the PAR, the PAR decision will be faxed.
- If the PAR was submitted via SPOT, the PAR decision will be available in SPOT. The decision will be communicated via SPOT based on the PTAN used within the SPOT account to submit a PAR not the PTAN on the coversheet.
A copy of the decision letter will be sent to the beneficiary.
The PAR decision letter will be postmarked or faxed within 7 calendar days following the receipt of the initial request. Note, weekends and federal/contractor holidays shall be included in the 7 calendar-day period.
The decision letter will include a unique transaction number (UTN) that is assigned to each PAR. Each UTN is specific to the beneficiary, provider and ASC facility on the PAR and the provisional affirmation, non-affirmation, or partial affirmation decision. The UTN must be submitted on the ASC facility claim in order to prevent prepayment review.
The PAR decision and UTN are valid for 120 days. The decision date shall be counted as the first day of the 120 days. For dates of service after the 120 days, the provider will need to submit a new PAR.
For example: If the PAR is affirmed on January 1, 2026, the PAR will be valid for dates of service through April 30, 2026.
Resubmission of a PAR
A resubmission PAR is any subsequent resubmissions to correct an error or omission identified during a PAR review. A resubmitted PAR is a request submitted with additional/updated documentation after the initial PAR was non-affirmed. A provider may resubmit a PAR an unlimited number of times upon receipt of a non-affirmative decision. A new UTN will be assigned with each PA resubmission request.
A resubmission PAR must contain previously submitted documentation along with additional and/or updated documentation. In addition to the required PAR documentation included in the initial PAR submission, the resubmission 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.
The resubmission PAR decision letter will be postmarked or faxed within 7 calendar days following the receipt of the resubmission request.
Expedited requests
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 processing timeframe.
First Coast will make reasonable efforts to communicate a decision within 2 business days of receipt of an accepted expedited request.
For an expedited review, complete the Prior authorization request ambulatory surgical center (ASC) procedures expedited Medicare Part B fax/mail cover sheet. First Coast will provide the decision to the provider via telephone, fax, electronic portal (SPOT), or other “real-time” communication, within the requisite timeframe.
Rejected PAR
A PAR is rejected when First Coast is unable to process the request due to incomplete or invalid information. First Coast will notify the submitter that their request was rejected and the reason why. Rejected prior authorization requests are not reviewed for medical necessity and are not considered non-affirmations.
When a PAR is rejected, the submitter should review the reason listed in the rejection letter. The submitter may then correct the error and submit the request again using the same submission procedures. When sending the corrections, all original documentation must also be included. If the rejected request was an initial request, the subsequent request should be marked as an initial request.
For more information common rejection reasons and corrective actions, please review the Prior Authorization (PA) Demonstration for Certain Ambulatory Surgical Center (ASC) Services Operational Guide.
Best practices
The following are best practices that will assist you in avoiding a delay or non-affirmation of a PAR.
To avoid potential scheduling issues, it is recommended that you do not schedule surgery until an approved prior authorization is received and to submit a PAR at least two weeks prior to the date the procedure is recommended to be performed. Remember, a provisional affirmation of a PAR is valid for 120 days from the decision date.
A retroactive prior authorization is not applicable. A PAR must be submitted before the service is provided to a beneficiary.
We highly recommend using the SPOT portal for submitting photos. SPOT will provide the best quality and clarity for photos since they can be submitted in color.
Submission of a claim without the UTN will result in a request for prepayment review. If the provider is actively within the PAR process, it is recommended to wait until the provider receives a decision before submitting a claim to avoid a prepayment additional records request.
Multiple or Staged Procedures
If multiple procedures on the PA list are to be performed on the same beneficiary on the same day, include all applicable procedures on a single PAR. Each prior authorization request will receive a single UTN, regardless of the number of procedures being requested.
If multiple procedures are performed on different dates of service within 120 days on the same beneficiary, each DOS needs a new PAR regardless of whether the next service falls within 120 days.
- For example, botulinum toxin injections performed 12 weeks apart, each DOS will need its own UTN, thus needing a separate PAR. Each UTN for botulinum toxin injections is valid for one DOS.
If a staged procedure is being performed with all procedures occurring within 120 days, each DOS needs a new PAR regardless of whether the next service falls within 120 days.
- For example, staged vein ablation services need a separate PAR for each DOS:
- Two procedures are performed on the left leg on January 20.
- Two more procedures are performed on the right leg on January 30.
- Each DOS requires a separate PAR to obtain a separate UTN for each DOS.
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Each UTN is valid for one claim per DOS.