Prior authorization program for certain hospital outpatient department services

Background

Education

Submissions

Quick links

General information

Events

Documentation

Contact information

 

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.

Education on related services

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.

Effective for dates of service (DOS) beginning July 1, 2023, CMS has added a new service category to the Hospital OPD PA program. This additional hospital OPD service category will require prior authorization as a condition of payment for facet joint interventions.

CMS provides a list of the specific HCPCS codes that are included in the OPD prior authorization program.

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.

Submissions

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.

Access the expedited OPD Prior Authorization Request (PAR) form 

Quick links

General information

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: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation.

Effective for DOS on or after July 1, 2021, the prior authorization applies to the following hospital OPD services: cervical fusion with disc removal and implanted spinal neurostimulators.

Effective for DOS on or after July 1, 2023, the prior authorization applies to the following hospital OPD services: facet joint interventions.

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 (UTN) will be assigned with each PAR. An initial decision letter will be issued within 10 business days of receipt of initial request. Resubmission notifications will be issued within 7 calendar days of receipt of the resubmission request.

Note: Effective for PARs received January 1, 2025, and after the decision letter will be issued within seven calendar days.

Upcoming events

Please visit our educational events calendar for all currently available training opportunities.

Documentation

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:

Dates of service Local coverage determination (LCD)/LCA/NCD Type of service
For services performed on or after July 11, 2021 LCD: Cosmetic and Reconstructive Surgery (L38914)  panniculectomy and rhinoplasty
For services performed on or after July 11, 2021 Local Coverage Article (LCA): Billing and Coding-Cosmetic and Reconstructive Surgery (A58573)  panniculectomy and rhinoplasty
For services performed on or after March 21, 2021 LCD: Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (L34028)  blepharoplasty
For services performed on or after March 21, 2021 LCA: Billing and Coding-Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow (A57025)  blepharoplasty
For services performed on or after March 21, 2021  LCD: Botulinum Toxins (L33274) botulinum toxins
For services performed on and after March 21, 2021 LCA: Billing and Coding-Botulinum Toxins (A57715)  botulinum toxins
For services performed on or after December 27, 2020 LCD: Treatment of Chronic Venous Insufficiency of the Lower Extremities (L38720)  vein ablation
For services performed on or after March 11, 2021 LCA: Billing and Coding-Treatment of Chronic Venous Insufficiency of the Lower Extremities (A58250)  vein ablation
National Coverage Determination (NCD) 160.7 NCD for Electrical Nerve Stimulators implanted spinal neurostimulators
For services performed on or after October 1, 2015 LCD: Facet Joint Interventions for Pain Management  facet joint interventions
Revision effective date: January 1, 2023 LCA: Billing and Coding: Facet Joint Interventions for Pain Management  facet joint interventions
For services performed on or after August 11, 2024 LCD: Cervical Fusion  cervical fusion
For services performed on or after August 11, 2024 LCA: Billing and Coding: Cervical Fusion  cervical fusion

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 

View additional information regarding overall prior authorization initiatives.