Prior authorization program for certain hospital outpatient department services
Prior authorization request (PAR) submission requirements
Background
CMS implemented a nationwide prior authorization program in July 2020 for certain hospital outpatient department (OPD) services, with additional services added in July 2021 and July 2023. CMS believes prior authorization for certain hospital OPD services will ensure that Medicare beneficiaries continue to receive medically necessary care while protecting the Medicare Trust Fund from improper payments and keeping the medical necessity documentation requirements unchanged for providers.
Overall, as a condition of payment, a prior authorization request (PAR) is required for the hospital OPD services listed below. Click on the available links to learn more about these services.
- Blepharoplasty, eyelid surgery, brow lift, and related services
- 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
- Cervical fusion with disc removal
- Implanted spinal neurostimulators
- Facet joint interventions
CMS provides a list of the specific HCPCS codes that are included in the OPD prior authorization program.
Providers can use the Prior Authorization Code Lookup Tool to the verify if a code is subject to hospital OPD PA. The results given by the tool will advise if the code is subject to PA.
Note: Since CMS has mandated prior authorization for these particular hospital OPD services as a condition of payment, when a prior authorization request (PAR) is received and it has been determined that the related procedure has already been rendered, the PAR will be non-affirmed.
| Question | Answer |
|---|---|
| Who | Hospital OPD when rendering certain OPD services for Medicare beneficiaries that bill Medicare Part A on a type of bill (TOB) 13X can receive prior authorization. |
| What | The hospital OPD (also known as the requestor) will be responsible to submit a prior authorization request (PAR) and all documentation for certain hospital outpatient services and their related services before the services are provided to Medicare beneficiaries and before the provider can submit claims for payment under Medicare for these services. |
| When |
Effective for DOS on or after July 1, 2020, the prior authorization applies to the following hospital OPD services:
Effective for DOS on or after July 1, 2021, the prior authorization applies to the following hospital OPD services:
Effective for DOS on or after July 1, 2023, the prior authorization applies to the following hospital OPD services:
|
| Where | The program applies to all jurisdictions nationwide. |
| Why |
CMS believes PA for certain hospital OPD services will ensure that Medicare beneficiaries continue to receive medically necessary care while protecting the Medicare Trust Fund from improper payments and keeping the medical necessity documentation requirements unchanged for providers. It is designed to ensure all relevant coverage, coding, payment rules, and medical record(s) requirements are met before the service is rendered to the beneficiary and the claim is submitted for payment. |
| How | Submit the PAR and all documentation. A unique tracking number will be assigned with each PAR. An initial decision letter will be issued within 7 calendar days following the receipt of initial request. Resubmission notifications will be issued within 7 calendar days of receipt of the resubmission request. |
Coverage policies
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, eyelid surgery, brow lift, and related services
- 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
- Cervical fusion with disc removal
- Implanted spinal neurostimulators
- Facet joint interventions
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) submission requirements
The hospital OPD, or provider on behalf of the hospital OPD, must submit the PAR to us 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.
- Prior authorization (PA) program for certain hospital outpatient department (OPD) services - submitting the prior authorization request (PAR)
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Prior authorization request hospital outpatient procedures Medicare Part A fax/mail cover sheet
- Note: This form is available for submission through the SPOT. If you do not have a SPOT account, learn how to register.
- Note: This form is available for submission through the SPOT. If you do not have a SPOT account, learn how to register.
- Hospital outpatient department prior authorization exemption process
- Hospital outpatient department (HOPD) services prior authorization (PA) calculator – determine when your authorization will expire
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 two business days of receipt an accepted expedited request.
Claim submission requirements
PA contact information
Prior authorization customer service phone number: 1-855-340-5975
Fax number: 1-855-815-3065
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 events calendar for all currently available training opportunities and to register to participate in webinars.
Quick links
- Prior Authorization for Certain Hospital Outpatient Department (OPD) Services
- Prior authorization process for certain hospital outpatient department (OPD) services frequently asked questions (FAQs)
- Prior authorization (PA) program for certain hospital outpatient department (OPD) services operational guide
- Final List of Outpatient Services That Require Prior Authorization
- Prior Authorization Code Lookup Tool