CMS may elect to exempt a hospital OPD provider from the hospital OPD prior authorization process upon a provider's demonstration of compliance with Medicare coverage, coding, and payment rules. This exemption would remain in effect for a six-month period or until CMS elects to withdraw the exemption.
First Coast will begin accepting prior authorization requests (PARs) for the following hospital outpatient department (OPD) services on June 17, 2020, for services provided beginning on or after July 1, 2020. To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for services.
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.
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.
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.
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]
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.
View these submission guidelines when submitting prior authorization requests for certain hospital outpatient department services
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