LICENSES AND NOTICES

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 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 including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials 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 & Medicaid Services (CMS). 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 websiteExternal Website.

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.

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. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. 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 CGS or the 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.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 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 BELOW ON THE BUTTON LABELED "I 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 BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" 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.

  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 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-4 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-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 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 American Dental Association websiteExternal Website.
  3. Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
  4. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 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-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 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.
  5. 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-4 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-4. 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.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.


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SHARE PRIOR AUTHORIZATION FEEDBACK

Prior Authorization

Medicare requires that all HCPCS codes that appear on the Required Prior Authorization ListExternal pdf must be submitted for prior authorization before delivery and claim submission. Refer to the Prior Authorization Process for DMEPOS Operational GuideExternal pdf for complete information and instructions. You can also use the Prior Authorization Lookup Tool to enter any HCPCS code and quickly determine if prior authorization is required.

The fastest, easiest way to submit prior authorization requests is through the DME myCGS portal.

Aside from the myCGS web portal, suppliers can submit PA requests via mailing address, fax, and esMD using the Prior Authorization (PA) Request CoversheetPDF. Submitting this coversheet gives you faster processing times, increased accuracy, organized submissions, and a lower risk of rejection. Place the Prior Authorization Request Coversheet first, before all other documentation.

Prior Authorization Additional Resources

HCPCS Codes

Lower Limb Prosthetics (LLP)

L5856, L5857, L5858, L5973, L5980, L5987

Orthoses

L0648, L0650, L1832, L1833, L1851

Implementation of this requirement will be completed in three phases:

  1. Phase one April 13, 2022, in New York, Illinois, Florida, and California.
  2. Phase two July 12, 2022, in Maryland, Pennsylvania, New Jersey Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington.
  3. Phase three October 10, 2022, in all remaining states and territories not included in phase 1 or phase 2. CGS began accepting Prior Authorization (PA) requests on September 26, 2022.

Power Mobility Device (PMD)

K0813-K0829, K0835-K0843, K0848-K0864.

Effective April 13, 2022: K0800, K0801, K0802, K0806, K0807, K0808. CGS began accepting PA requests for these codes on March 30, 2022.

Pressure Reducing Support Surfaces (PRSS)

E0193, E0277, E0371, E0372, E0373



Prior Authorization vs Advanced Determination of Medicare Coverage

 

ADMC

LLP

Orthoses

PMD

PRSS

States

Nationwide

Nationwide

Phase 1 April 13, 2022: New York, Illinois, Florida, and California

Phase 2 July 12, 2022: Maryland, Pennsylvania, New Jersey, Michigan, Ohio, Kentucky, Texas, North Carolina, Georgia, Missouri, Arizona, and Washington

Phase 3 October 10, 2022: Remaining states and territories

Nationwide

Nationwide

HCPCS

E1161, E1231-E1234, K0005, K0008, K0009, K0890, K0891, K0013

L5856, L5857, L5858, L5973, L5980, L5987

L0648, L0650, L1832, L1833, L1851

K0813-K0829, K0835-K0843, and K0848-K0864.

Effective April 13, 2022: K0800, K0801, K0802, K0806, K0807, and K0808

E0193, E0277, E0371, E0372, E0373

Requests Accepted From

Beneficiary or supplier

Beneficiary or supplier

Beneficiary or supplier

Beneficiary or supplier

Beneficiary or supplier

Decisions

30 calendar days

10 business days

Expedited: 2 business days

5 business days

Expedited: 2 business days

10 business days

Expedited: 2 business days

5 business days

Expedited: 2 business days

Letter Recipients

Supplier and beneficiary

Supplier and beneficiary or physician, if specifically requested

Supplier and beneficiary or physician, if specifically requested

Supplier and beneficiary or physician, if specifically requested

Supplier and beneficiary or physician, if specifically requested

Delivery Timeframes

The delivery must be within 6 months following the determination.

PAR decisions for these codes will remain valid for one hundred and twenty (120) calendar days following the provisional affirmation review decision.

PAR decisions for these codes will remain valid for sixty (60) calendar days following the provisional affirmation review decision.

PAR decisions for these codes will remain valid for six months following the "affirmed" review decision.

PAR decisions for these codes will remain valid for one month following the "affirmed" review decision.

Resubmissions

One resubmission in a 6-month period

Unlimited

Unlimited

Unlimited

Unlimited

Payments

Voluntary program

Any claim eligible for this program must be prior authorized before delivery of the item or it will be denied as prior authorization is a condition of payment.

Exclusions: The following claim types are excluded from any PA program described in this operational guide, unless otherwise specified:

  • Veterans Affairs
  • Indian Health Services
  • Medicare Advantage
  • Part A and Part B Demonstrations

Any claim eligible for this program must be prior authorized before delivery of the item or it will be denied as prior authorization is a condition of payment, unless an acute or competitive bidding program exception applies.

Exclusions: The following claim types are excluded from any PA program described in the operational guide, unless otherwise specified:

    • Veterans Affairs
    • Indian Health Services
    • Medicare Advantage
    • Part A and Part B Demonstrations

Any claim eligible for this program must be prior authorized before delivery of the item or it will be denied as prior authorization is a condition of payment.

Exclusions: The following claim types are excluded from any PA program described in this operational guide, unless otherwise specified:

  • Veterans Affairs
  • Indian Health Services
  • Medicare Advantage
  • Part A and Part B Demonstrations

Any claim eligible for this program must be prior authorized before delivery of the item or it will be denied as prior authorization is a condition of payment.

Exclusions: The following claim types are excluded from any PA program described in this operational guide, unless otherwise specified:

  • Veterans Affairs
  • Indian Health Services
  • Medicare Advantage
  • Part A and Part B Demonstrations

Appeals

ADMC is not eligible for appeal

Standard appeals process applies when claim is denied due to no PAR submitted, in addition to:

  • No GA modifier appended on claim (CO denial)
  • GA modifier is appended and Advance Beneficiary Notice of Noncoverage (ABN) deemed missing or invalid (CO denial)
  • GA modifier is appended and ABN deemed valid (PR denial)

Standard appeals process applies when claim is denied due to no PAR submitted, in addition to:

  • No GA modifier appended on claim (CO denial)
  • GA modifier is appended and Advance Beneficiary Notice of Noncoverage (ABN) deemed missing or invalid (CO denial)
  • GA modifier is appended and ABN deemed valid (PR denial)

Standard appeals process applies when claim is denied due to no PAR submitted, in addition to:

  • No GA modifier appended on claim (CO denial)
  • GA modifier is appended and Advance Beneficiary Notice of Noncoverage (ABN) deemed missing or invalid (CO denial)
  • GA modifier is appended and ABN deemed valid (PR denial)

Standard appeals process applies when claim is denied due to no PAR submitted, in addition to:

  • No GA modifier appended on claim (CO denial)
  • GA modifier is appended and Advance Beneficiary Notice of Noncoverage (ABN) deemed missing or invalid (CO denial)
  • GA modifier is appended and ABN deemed valid (PR denial)

Revised: 10.13.22

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