Prior authorization (PA) demonstration for certain ambulatory surgical center (ASC) services
Background
General information
Coverage policies
Documentation requirements
Prior authorization requests (PARs)
Expedited request
Claim submission guidelines
Prior authorization department contact information
Educational events
References
Background
CMS is implementing a five-year demonstration project for the prior authorization of certain services provided in Ambulatory Surgical Centers (ASCs), for limited number of demonstration states effective for dates of services (DOS) on or after December 15, 2025. The demonstration states are California, Florida, Texas, Arizona, Ohio, Tennessee, Pennsylvania, Maryland, Georgia, and New York.
The service categories targeted by the demonstration are:
- Blepharoplasty
- Botulinum toxin injections
- Panniculectomy
- Rhinoplasty
- Vein ablation
CMS believes this demonstration will help address potential fraud, no matter how prevalent incidences may be in a particular state, by discouraging the submission of potentially fraudulent claims and providing education to providers. Additionally, CMS believes this demonstration will assist in developing improved procedures for the identification, investigation, and prosecution of potential Medicare fraud occurring among ASCs providing the target services.
General information
PA demonstration for certain services provided in ASCs guidelines.
| Question | Answer |
|---|---|
| Who | ASCs rendering certain service for Medicare beneficiaries that bill Medicare Part B in a place of service (POS) 24. As part of this demonstration, ASC facilities will be subject to PA or prepayment review further defined by type of service F and provider specialty code 49. |
| What |
CMS is implementing a five-year demonstration project for the PA of the following services provided in ASCs effective for DOS on or after December 15, 2025:
CMS provides a list of the specific procedure codes included in the PA demonstration for services provided in an ASC. |
| When | First Coast will begin accepting prior authorization requests (PARs) on December 1, 2025, for DOS on or after December 15, 2025. |
| Where | For First Coast, the demonstration will apply to certain ASC services provided in the state of Florida. |
| Why | CMS believes this demonstration will help address potential fraud, no matter how prevalent incidences may be in a particular state, by discouraging the submission of potentially fraudulent claims and providing education to providers. Additionally, CMS believes this demonstration will assist in developing improved procedures for the identification, investigation, and prosecution of potential Medicare fraud occurring among ASCs providing the target services. |
| How |
This demonstration will help ensure eligible treating providers in ASCs are only performing the targeted services for beneficiaries in accordance with Medicare guidelines. The ASCs will obtain PA before the services are provided to Medicare beneficiaries, or the provider will be subjected to prepayment review and potentially be denied payment if services are deemed ineligible. Submit the PAR and all documentation via: First Coast will review the information submitted and issue a decision (affirmation, non-affirmation, or partial affirmation) to the provider. |
Coverage policies
| LCD/Billing and Coding/NCD articles | Type of service |
|---|---|
| LCD: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (L34028) | Blepharoplasty |
| Billing and Coding: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A57025) | Blepharoplasty |
| CMS IOM Pub. 100-02 Medicare Benefit Policy Manual, Chapter 1, section 30 | Botulinum toxin injections |
| LCD: Botulinum Toxins (L33274) | Botulinum toxin injections |
| Billing and Coding: Botulinum Toxins (A57715) | Botulinum toxin injections |
| LCD: Cosmetic and Reconstructive Surgery (L38914) | Panniculectomy and rhinoplasty |
| Billing and Coding: Cosmetic and Reconstructive Surgery (A58573) | Panniculectomy and rhinoplasty |
| LCD: Treatment of Chronic Venous Insufficiency of the Lower Extremities (L38720) | Vein ablation |
| Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities (A58250) | Vein ablation |
Documentation requirements
To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for services. For more information on coverage and documentation requirements, refer to the following articles.
- Blepharoplasty, blepharoptosis repair and brow ptosis repair
- 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
For any service or item to be covered by Medicare, it must:
- Be eligible for a defined Medicare benefit category.
- Be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
- Meet all other applicable Medicare statutory and regulatory requirements.
Prior authorization request (PAR)
The ASC, or provider on behalf of the ASC, must submit the PAR to us before the service is provided to the beneficiary and before the claim is submitted for processing. If a PAR is not submitted, the ASC facility claim will subject to prepayment review.
The PAR must include all documentation necessary to show that the service meets applicable Medicare coverage, coding, and payment rules.
- Ambulatory surgical center (ASC) prior authorization request (PAR) submission guidelines (coming soon)
- Prior authorization request ambulatory surgical center (ASC) procedures Medicare Part B fax/mail coversheet (coming soon)
- Prior authorization request (PAR) coversheet instructions (coming soon)
- Prior authorization (PA) calculator (coming soon)
Expedited request
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 timeframe. We will make reasonable efforts to communicate a decision within two business days of receipt an accepted expedited request.
Claim submission guidelines
The UTN included in the decision letter should only be reported on the Part B ASC facility claim (POS 24).
- Ambulatory surgical center (ASC) prior authorization (PA) claim submission guidelines (coming soon)
Prior authorization department contact information
Prior authorization customer service phone number:
855-340-5975 available Monday-Friday, 8 a.m.-6 p.m. ET
Fax number:
855-815-3065
Mailing address:
First Coast Service Options, Inc.
JN Prior Authorization
PO Box 3033
Mechanicsburg, PA 17055-1804
Priority mailing address:
First Coast Service Options, Inc.
Attention: JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg, PA 17050
Educational events
Please visit our educational event calendar for all available training opportunities and to register to participate in the webinars.
References
- Prior Authorization Demonstration for Certain Ambulatory Surgical Center (ASC) Services
- Prior Authorization (PA) Demonstration for Certain Ambulatory Surgical Center (ASC) Services Operational Guide
- Prior Authorization Demonstration for Certain Ambulatory Surgical Center Services Frequently Asked Questions (FAQs)
- List of Ambulatory Surgical Center Services For Prior Authorization
- Ambulatory surgical center