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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. Remember hospital OPD PA is a condition of payment and completing the procedure before the review will result in denial of payment.

To submit a PAR, complete the Prior Authorization Request Hospital Outpatient Procedures Medicare Part A Fax/Mail Cover Sheet and follow the instructions for completing the cover sheet.
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 to avoid potential delays in processing of the initial submission documents. 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 CMS Final list of outpatient department services that require prior authorization on the PAR. Providers can use the Prior authorization code lookup tool to verify if a code requires PA. 

PAR fax/mail cover sheet elements and instructions

Complete all applicable fields on the fax/mail cover sheet for data elements listed and attach supporting medical documentation. Complete one fax/mail cover sheet 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.
Facility NPI  Enter the hospital outpatient department's 10-digit National Provider Identifier (NPI).
Facility CCN/PTAN Enter the hospital outpatient department's 6-digit CMS certification number (CCN). This is sometimes referred to as the Provider Transaction Access Number (PTAN).
Facility fax number Enter the hospital outpatient department's fax number. This will enable the HOPD to receive the prior authorization decision letter.
Facility name and address  Enter the hospital outpatient department'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 prior authorization 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 prior authorization 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 prior authorization fax / mail cover sheet and medical records.
Alternative phone number and/or Direct extension Enter an alternate 10-digit phone number (XXX-XXX-XXXX) or extension when we can reach to the requestor, if necessary.
Procedure code(s) Enter the procedure code for the outpatient service requiring the PA. Refer to the CMS list of the specific HCPCS codes that are included in the OPD PA program.
Modifier Select the appropriate modifier, either RT, LT or 50.
Site(s)/Level(s) Enter the site/level, as applicable for the requested outpatient department services.
Unit of services Enter the number of units being requested.
Request type Select whether it is an initial submission or a resubmission.
Diagnosis codes (esMD submission only) Enter the diagnosis codes for the conditions necessitating the hospital outpatient department services. Providers who submit using esMD must include diagnosis code(s).
Anticipated date of service Enter the date for anticipated date of service.
State (location) of authorization  Enter the state based on where the hospital outpatient department is located.
Date submitted Provide the date the coversheet was completed/submitted in MM/DD/YYY format.
Comments Please enter previous non-affirm UTN for resubmission requests, change in facility, record updates or reasons for expedited review. Any additional information applicable to assist with medical review.

Note: Do not use the expedited prior authorization request cover sheet unless the normal timeframe for a decision notification could jeopardize the life or health of the beneficiary. If the medical records submitted with the expedited request do not justify an expedited request, then the request will be subject to the normal process and timeframes.

Submitting the PAR

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

  • SPOT
    • The PAR cover sheet is built into the portal. Complete fields as required and upload supporting documentation.
  • Mail:
    • First Coast Service Options, Inc.
      JN Prior Authorization
      PO Box 3033
      Mechanicsburg, PA 17055-1804

  • Fax: 1-855-815-3065

  • esMD (content type 8.5)

PAR review and decisions

First Coast will review the information submitted and the decision will be issued to the requestor and the hospital OPD facility address listed on the PAR.
The decision that can result from the PAR review includes 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 hospital OPD facility address 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 hospital OPD facility on the PAR and the provisional affirmation, non-affirmation, or partial affirmation decision. The UTN must be submitted on the hospital OPD facility claim. 
The PAR decision and UTN are valid for 120 calendar days. The decision date shall be counted as the first day of the 120 days. For dates of service after 120 calendar 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 the 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 timeframe. First Coast will make reasonable efforts to communicate a decision within 2 business days of receipt an accepted expedited request.

For an expedited review, complete the Prior Authorization Request Hospital Outpatient Procedures Expedited Medicare Part A 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 required 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) program for certain hospital outpatient (OPD) services operational guide.

Best practices, tips, and reminders

The following are best practices, tips, and reminders to assist 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. Faxed photos are only black and white and do not have sufficient detail required to support the PAR.
  • To prevent the claim from being stopped for prepayment review, the provider should hold their claim and not submit it until the UTN is provided and can be appended to the claim.
  • When submitting a PAR, please ensure you are submitting only one fax coversheet. For PAR resubmissions, discard any previous fax coversheets and create a new one to submit with all the documentation to be reviewed, not just what was missing from your prior PAR. Submission of multiple coversheets will cause a delay in the review and can result in a dismissal or non-affirmation, as it breaks up the documentation into more than one request when there are multiple fax coversheets. 
  • Ensure the fax numbers submitted are true fax numbers. An increase in erroneous fax numbers has been noted with PARs.
  • Ensure the contact person listed has a direct phone number to reach them. An increase in general provider phone numbers with the inability to reach the contact person has been identified. If the clinical reviewer has a question, it is key they be able to reach the contact person. If they are unable to do so, then a non-affirmation may result, delaying the service requested.
  • There have been PARs received in which documentation is redacted. This is not allowed, and the case will be dismissed. 

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.
    • Each UTN is valid for one claim per DOS.

References