Understanding the prior authorization (PA) demonstration for ambulatory surgical center (ASC) services
The following document was developed based on questions and answers posed during our webinars on the PA demonstration for ASC services.
For details, links and submission guidelines, refer to the webpage on the Prior authorization (PA) demonstration for certain ambulatory surgical center (ASC) services.
Prior authorization (PA) code lookup tool
1Q: How can I verify if the service being provided in an ASC is subject to PA?
1A: CMS provides a list of the specific procedure codes included in the ASC PA demonstration.
Additionally, providers can use the Prior Authorization Code Lookup Tool to verify if a code is subject to ASC PA. To use the tool, select Part A or Part B for the type of claim the provider will be submitting and enter any Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) code. The results will indicate if the code is subject to PA.
2Q: If I use the prior authorization (PA) code lookup tool, will I be provided with a reference number?
2A: No, a reference number is not provided when using the tool and is not required to submit a prior authorization. Please, do not call the Provider Contact Center to ask for a reference number.
Prior authorization request (PAR)
1Q: Does the ASC have to include the anesthesia CPT code with their PAR? Will the anesthesia code fall under the authorization for the surgical CPT code?
1A: Only report the procedure code(s) subject to PA on the PAR.
Associated/related (professional) services are not subject to PA but will be denied when there was a non-affirmation PAR decision for the ASC service(s), or when the ASC facility claim was denied after prepayment review. These associated services include but are not limited to services such as anesthesiology services and/or physician services.
2Q: The PAR ASC fax/mail coversheet allows for three procedure codes to be listed. If I have additional procedure codes needing PA for this submission, where do I place these additional procedure codes?
2A: If additional procedures need to be added to the PAR ASC fax/mail coversheet, use the comment box to communicate the additional procedure code(s) along with the corresponding modifiers, site/level and units of service, as appropriate. Do not submit multiple PAR fax/mail coversheets for one PAR submission.
Claim submission
1Q: If a service receives a non-affirmed PA decision and we submit a claim with the GA modifier, will the records have to be resubmitted during the additional documentation request (ADR) process, or will they be used from the PAR?
1A: The records, including a copy of the signed Advanced Beneficiary Notice (ABN), will need to be submitted for an ADR request.
Questions
Questions regarding topics not currently defined in CMS or First Coast published resources related to the PA demonstration for ASC services can be sent to ASC_PA@cms.hhs.gov
If you have questions regarding Medicare processing, please contact PA customer service at: 855-340-5975.