Prior Authorization Program Initiatives
CMS sponsors a variety of programs intended to safeguard beneficiary access to medically necessary items and services while reducing improper Medicare billing and payment. Prior authorization (PA) serves as a screening mechanism to help CMS ensure continued compliance with Medicare coverage requirements.
Under prior authorization, the provider or supplier submits the prior authorization request (PAR) and supportive medical documentation to the MAC and receives an affirmed or non-affirmed decision prior to rendering the service. These initiatives do not change any medical necessity or documentation requirements.
Providers can use the Prior Authorization Code Lookup Tool to verify if a code is subject to PA programs which include hospital outpatient departments (OPD), ambulatory surgical centers (ASC) and repetitive scheduled non-emergent ambulance transports (RSNAT). The results given by the tool will advise if the code is subject to a PA program.
| Active initiatives | Details |
|---|---|
| Prior Authorization Demonstration for Certain Ambulatory Surgical Center Services |
CMS is implementing a 5-year demonstration project for the PA of certain services provided in ASCs located in a limited number of demonstration states and will be implementing the demonstration in two phases:
Service categories targeted by the demonstration are:
PA for the ASC demonstration is voluntary. However, if a provider elects to bypass PA, applicable ASC claims will be subject to a prepayment medical review. |
| Prior Authorization Program for Certain Hospital Outpatient Department Services |
Effective: DOS on or after July 1, 2020 PAR is required for the following hospital OPD services:
Effective: DOS on or after July 1, 2021 PAR is required for these two additional hospital OPD services:
Effective: DOS on or after July 1, 2023 PAR is required for the following new service category:
|
| Prior Authorization Program for Repetitive Scheduled Non-Emergent Ambulance Transport |
CMS began operating the ambulance RSNAT PA model program in limited states in 2014 under the authority of the Social Security Act. The model became fully operational nationwide on August 1, 2022.
|
Prior Authorization Contact Center
Questions and concerns on the ASC, OPD, RSNAT prior authorization initiatives can be directed to the following:
Phone:
855-340-5975 available Monday-Friday, 8 a.m.-6 p.m. ET
Fax:
855-815-3065
Mail:
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
References