skip to content
Thank you for visiting First Coast Service Options' Medicare provider website. This website is intended exclusively for Medicare providers and health care industry professionals to find the latest Medicare news and information affecting the provider community.
To enable us to present you with customized content that focuses on your area of interest, please select your preferences below:
Select which best describes you:
Select your location:
Select your line of business:

By clicking Continue below you agree to the following:

LICENSE FOR USE OF "PHYSICIAN'S CURRENT PROCEDURAL TERMINOLOGY" (CPT), FOURTH EDITION End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2022 American Medical Association (AMA).

All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.
You, your employees, and agents are authorized to use CPT only as contained in the following authorized materials:
Local Coverage Determinations (LCDs),
Local Medical Review Policies (LMRPs),
Bulletins/Newsletters,
Program Memoranda and Billing Instructions,
Coverage and Coding Policies,
Program Integrity Bulletins and Information,
Educational/Training Materials,
Special mailings,
Fee Schedules;

internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS), formerly known as Health Care Financing Administration (HCFA). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website. Applicable FARS/DFARS restrictions apply to government use.

AMA Disclaimer of Warranties and Liabilities CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this agreement.

CMS Disclaimer: The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

AMA - U.S. Government Rights

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a )June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

ADA CURRENT DENTAL TERMINOLOGY, (CDT)
End User/Point and Click Agreement: These materials contain Current Dental Terminology (CDTTM), Copyright © 2016 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING ON THE BUTTON LABELED "ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK ON THE BUTTON LABELED "DECLINE" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the ADA website.

Applicable Federal Acquisition Regulation Clauses (FARS)\Department of restrictions apply to Government Use.

ADA DISCLAIMER OF WARRANTIES AND LIABILITIES: CDT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third party beneficiary to this Agreement.

CMS DISCLAIMER: The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

End Disclaimer


This website provides information and news about the Medicare program for health care professionals only. All communication and issues regarding your Medicare benefits are handled directly by Medicare and not through this website. For the most comprehensive experience, we encourage you to visit Medicare.gov or call 1-800-MEDICARE. In the event your provider fails to submit your Medicare claim, please view these resources for claim assistance.
Join eNews       En Español
Text Size:
YouTube LinkedIn Email Print
Send a link to this page
[Multiple email addresses must be separated by a semicolon.]

Prior authorization

Modified: 11/19/2024
The following document was developed based on questions and answers posed during our webinars on the prior authorization (PA) program for certain hospital outpatient department (OPD) services.
Modified: 11/19/2024
When submitting prior authorization requests, be aware of response timeframes and documentation guidelines.
When submitting prior authorization requests, be aware of response timeframes and documentation guidelines.
Modified: 11/19/2024
When submitting a prior authorization request (PAR), be mindful of specific guidelines relating to proper submission to avoid potential non-affirmations. Review this article to avoid non-affirmations.
Modified: 11/19/2024
CMS implemented a prior authorization program for certain hospital outpatient department services for dates of service on or after July 1, 2020.
Modified: 11/13/2024
Effective for dates of service July 1, 2021, and after, hospital outpatient department (HOPD) providers will need to obtain prior authorization (PA) for cervical fusion with disc removal if performed in a HOPD setting and billed with the follow CPT codes: 22551 and 22552.
Modified: 10/4/2024
CMS implemented a prior authorization program for repetitive scheduled non-emergency ambulance transport for dates of service on or after April 1, 2022.
Modified: 8/8/2024
CMS has removed CPT codes 64492 and 64495 from the listing of codes requiring prior authorization. View our article to learn more about these changes.
Modified: 8/8/2024
Facet joint interventions may be used in pain management for chronic cervical/thoracic and lumbar/sacral pain arising from the paravertebral facet joints. Imaging guidance (fluoroscopy or CT per code descriptor) is used to assure accurate placement of the needle for the injection. Paravertebral facet joint denervation is a therapeutic intervention used to provide both long-term pain relief and reduce the likelihood of recurrence of chronic cervical/thoracic or lumbar/sacral pain confirmed as originating in the facet joint’s medial branch nerve.
Modified: 8/8/2024
To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for services.
Modified: 6/28/2024
Use this calculator to determine the time remaining to perform the approved procedure before the authorization expires.
Modified: 5/10/2024
A repetitive service is defined as medically necessary ambulance transportation that is furnished three or more times during a 10-day period OR at least once per week for at least three weeks. Repetitive ambulance services are often needed by beneficiaries receiving dialysis or cancer treatment.
Modified: 5/3/2024
Botulinum toxins are potent neuromuscular blocking agents that are useful in treating various focal muscle spastic disorders and excessive muscle contractions, such as dystonia, spasms, and twitches.
Modified: 5/3/2024
The following are tips and reminders that will assist providers in avoiding a delay or dismissal of a Prior Authorization Request.
Modified: 4/26/2024
Prior authorization is a process through which coverage is determined prior to providing or billing the service. This process allows the provider to submit documentation prior to providing or billing the service. The contractor will then alert the submitter of any potential issues with the submitted information.
Modified: 4/26/2024
CMS is releasing results from the first year of the Non-Emergent Hyperbaric Oxygen (HBO) Therapy Prior Authorization model. [CR9940]
Modified: 4/25/2024
Physician certification statements (PCS) are required for patients who are under the direct care of a physician and are required to verify the medical necessity for certain scheduled and unscheduled non-emergency ambulance transports. Read this article to learn more.
Modified: 4/19/2024
View this prior authorization request coversheet for repetitive, scheduled non-emergent ambulance transport (RSNAT).
Modified: 4/19/2024
Are you sending hardcopy mail to submit your requests to First Coast? Did you know there are faster and easier ways to send your requests to us? Avoid the wait. Learn about the electronic options available for you to submit prior authorization requests.
Modified: 4/16/2024
CMS is implementing a prior authorization program for certain hospital outpatient department services for dates of service on or after July 1, 2020. Review the fax coversheet needed for submission.
Modified: 4/12/2024
First Coast sent letters to providers announcing the expansion of the repetitive, scheduled, non-emergent ambulance transport (RSNAT) in jurisdiction J (JN) effective April 1, 2022.
Modified: 4/12/2024
View these submission guidelines when submitting prior authorization requests for certain hospital outpatient department services
Modified: 4/12/2024
Expedited prior authorization request hospital outpatient procedures Medicare Part A Fax/Mail Coversheet - Allowable if it is determined that a delay could seriously jeopardize the beneficiary’s life, health, or ability to regain maximum function.
Modified: 4/12/2024
Repetitive, scheduled non-emergent ambulance transport (RSNAT) has been effective as of April 1, 2022. Through this program, a unique tracking number (UTN) is issued for each medical decision provided – whether affirmed or non-affirmed. When submitting corresponding claims, this UTN should be placed in the UTN# field.
Modified: 4/12/2024
Claims submitted for a prior authorization request (PAR) that received a provisional affirmation PA decision, including any service that was part of a partially affirmed decision, must include the 14-byte unique tracking number (UTN) number listed on the decision letter. The hospital OPD claim is reported on a type of bill 13X. If all Medicare coverage, coding, and payment requirements are met, the claim will likely be paid.
Modified: 4/12/2024
The PA team has been receiving and processing prior authorization requests (PAR) for certain hospital OPD services. View the following reminders prior to submitting your request
Modified: 4/12/2024
The repetitive scheduled non-emergent ambulance transport (RSNAT) prior authorization request submission checklist helps you identify all required elements on the prior authorization request (PAR) are included with your submission.
Modified: 4/7/2024
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) expands the repetitive scheduled non-emergent ambulance transport prior authorization model to all states if the program meets certain requirements. [CR9940]
Modified: 4/5/2024
To submit a prior authorization request, complete the prior authorization coversheet. Failure to populate every field could result in delays in processing your request, a non-affirmed decision, or a determination that the request is incomplete and cannot be processed.
Modified: 4/5/2024
Follow this instructions to learn how to file a claim once you received the unique tracking number (UTN) related to the prior authorization of repetitive, scheduled non-emergency ambulance transports.
Modified: 3/29/2024
Vein ablation and related services; some patients may want varicose vein treatment for cosmetic reasons. Medicare does not cover cosmetic surgery or expenses incurred in connection with such surgery.
Modified: 3/25/2024
This article is designed to assist medical providers with documenting the beneficiary’s medical condition supporting coverage for non-emergent ambulance transportation.
Modified: 3/25/2024
The following article provides a list of common terms used by the medical review department for prior authorization requests.
Modified: 3/22/2024
Review this checklist to learn about the documentation requirements for medical professionals related to the repetitive, scheduled, non-emergency prior authorization program.
Modified: 3/22/2024
Review these FAQs to learn more about the prior authorization for repetitive scheduled non-emergency ambulance transport.
Modified: 3/15/2024
Hospital outpatient departments (OPDs) who demonstrate compliance with Medicare coverage, coding, and payment rules related to prior authorization (PA) may be eligible for exemption. This exemption would remain in effect for a 12-month period or until CMS elects to withdraw the exemption.
Modified: 3/15/2024
CMS covers the implantation of central nervous system stimulators as a therapy for the relief of chronic intractable pain.
Modified: 3/15/2024
Learn how to complete the the prior authorization request (PAR) coversheet for repetitive scheduled non-emergency ambulance transports.
Modified: 3/15/2024
Prior Authorization Request Hospital Outpatient Procedures Medicare Part A Fax/Mail Coversheet
Modified: 3/1/2024
Review this checklist to learn about the documentation requirements to ensure an affirmed decision on your prior authorization request (PAR) for repetitive, scheduled, non-emergency transport.
Modified: 2/23/2024
Effective for dates of service July 1, 2020, and after, hospital outpatient department (HOPD) providers will need to obtain prior authorization (PA) for panniculectomy, excision of excess skin and subcutaneous tissue (including lipectomy), and related services if performed in a HOPD and billed with the following CPT codes.
Modified: 2/21/2024
Are you participating in prior authorization and want to know how to maintain exemption within this program? Do you have questions regarding the different timeframes and dates relating to the deadlines and requirements associated with prior authorization exemption? This new video was created to address exactly those questions.
Modified: 2/16/2024
CMS has implemented the prior authorization program for certain repetitive, scheduled non-emergent ambulance transports in Florida, Puerto Rico and the US Virgin Islands. Learn more about the program and how you can participate.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.