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.
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
| Dates of service | Local coverage determination (LCD)/Billing and Coding/National coverage determination (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 | 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 | 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 | 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 | 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 | 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 | Billing and Coding: Cervical Fusion | cervical fusion |
Documentation requirements
To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for 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
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
- View instructions for submitting OPD prior authorization requests
- Exemption process for hospital outpatient department (OPD) providers
- Access the OPD prior authorization request (PAR) form
- 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.
- Prior authorization coversheet instructions
- Submission tips and reminder
- Reminder: Stay timely with your PAR submissions – View timeliness details
- Reminder: Stay timely with your PAR submissions – View timeliness details
- Prior authorization requests (PARs): How to avoid potential non-affirmations
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
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.
Quick links
- Hospital outpatient department (HOPD) services prior authorization (PA) calculator – determine when your authorization will expire
- View claim submission guidelines for certain hospital OPD services
- CMS Prior Authorization for Certain Hospital Outpatient Department (OPD) Services
- CMS OPD Frequently Asked Questions
- CMS OPD Operational Guide
- CMS Final List of Outpatient Services That Require Prior Authorization