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 |
|---|---|
| PA demonstration for certain ASC 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. |
| PA program for certain hospital OPD services |
Overall, as a condition of payment, a prior authorization request (PAR) is required for the hospital OPD services listed below:
CMS provides a list of the specific procedure codes that are included in the OPD PA program. |
| PA program for (RSNAT) |
Effective March 18, 2022, CMS started the prior authorization for certain repetitive scheduled non-emergent ambulance transports for dates of service on or after April 1, 2022, in Florida, Puerto Rico and the U.S. Virgin Islands. By submitting a completed coversheet, and the required documentation, a supplier can receive provisional prior authorization for as many as 40 round trips (80 one-way transports) in a 60-day period.
Note: Prior authorization requests (PARs) may be submitted through SPOT. The PAR form may be accessed under SPOT’s Submit Documentation feature. Please review the SPOT User Guide for more details.
|
Contact information
Questions and concerns on the 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