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Prior authorization (PA) program for certain hospital outpatient department (OPD) services - submitting the prior authorization request (PAR)

The hospital OPD provider must submit the PAR to First Coast before the service is provided to the beneficiary and before the claim is submitted for processing.  The PAR must include all documentation necessary to show that the service meets applicable Medicare coverage, coding, and payment rules.

The requester, or the person or entity that submits the PAR, documentation, and /or claims, must include the data elements below in all PARs to avoid potential delays in processing of the initial submission documents.

Beneficiary information

  • Beneficiary first and last name
  • Medicare Beneficiary Identifier (MBI)
  • Beneficiary date of birth

Hospital OPD information (facility)

  • Facility National Provider Identifier (NPI)
  • Facility CMS certification number (CCN) or PTAN
  • Facility fax number
  • Facility name and address

Physician / Practitioner information (provider)

  • Physician / Practitioner’s NPI
  • Physician / Practitioner’s name and address
  • Physician / Practitioner PTAN
  • Physician / Practitioner fax number

Requestor information 

  • Requestor name
  • Requestor Email address
  • Requestor phone number
  • Requestor alternate phone number and/or direct extension 

Other information 

  • Request type
  • Procedure code(s)
  • Modifier
  • Site / Level
  • Units of service
  • Diagnosis codes (esMD submission only)
  • Anticipated date of service
  • State (location) of authorization
  • Date submitted
  • Comments 

Resubmission(s) documentation

  • In addition to the required PAR documentation in the initial submission section, the resubmission of the 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.

Sending a PAR

Requesters have the following options for submitting PARs to First Coast: 

  1. Mail
  2. Fax
  3. esMD (content type 8.5)
  4. SPOT

First Coast contact information

First Coast Service Options, Inc.

JN Prior Authorization

PO Box 3033 

Mechanicsburg, PA 17055-1804

Fax#: 1-855-815-3065

Phone #: 1-855-340-5975 (Prior Auth Customer Service)

Website: medicare.fcso.com

esMD: indicate document/content type “8.5”

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 timeframe. First Coast Service Options will make reasonable efforts to communicate a decision within two business days of receipt an accepted expedited request.

References