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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.

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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.

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  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.
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Prior Authorization

The following table summarizes the key differences between Advance Determination of Medicare Coverage (ADMC) and the Prior Authorization Program for Power Mobility Devices (PMDs).

Topic Brief Description

Advanced Determination of Medicare Coverage (ADMC)

Advance Determination of Medicare Coverage (ADMC) is a voluntary program that allows Suppliers and Beneficiaries to request prior approval of "eligible" items before delivery of the items to the beneficiary. At this time, only customized wheelchairs (manual and power) are eligible for ADMC

Group 2 PRSS Prior Authorization Program

CMS has added the following five HCPCS codes for Group 2 Pressure Reducing Support Surfaces (PRSS) to the Required Prior Authorization List: E0193, E0277, E0371, E0372, and E0373. As of October 21, 2019, prior authorization of these codes is required for all states and territories.

Lower Limb Prosthetics Prior Authorization

CMS has added the following six HCPCS codes for Lower Limb Prosthetics (LLP) to the Required Prior Authorization list: L5856, L5857, L5858, L5973, L5980, and L5987 (functional level 3 or above). Prior Authorization for LLPs will be implemented in two phases.

Phase 1

For items furnished on or after September 1, 2020 in one state from each DME MAC jurisdiction: California, Michigan, Pennsylvania, and Texas. CGS began accepting prior authorization requests on August 18, 2020.

Phase 2

Will begin for items furnished on or after December 1, 2020 and expands required prior authorization of these codes to all of the remaining states and territories. The DME MACs began accepting prior authorization requests for the remaining states and territories on November 17, 2020.

PMD Prior Authorization Program

All new rental series claims for HCPCS Codes K0813-K0829, K0835-K0843, and K0848-K0864 with a date of delivery on or after July 22, 2019 must be associated with a prior authorization request as a condition of payment. Therefore, lack of a provisionally affirmed prior authorization request will result in a claim denial.

  ADMC Lower Limb Prosthetics PA Program PMD PA Program PRSS PA Program

States

  • Nationwide
  • For items furnished on or after September 1, 2020 in one state from each DME MAC jurisdiction: California, Michigan, Pennsylvania, and Texas. CGS began accepting prior authorization requests on August 18, 2020.
  • Will begin for items furnished on or after December 1, 2020 and expands required prior authorization of these codes to all of the remaining states and territories. The DME MACs began accepting prior authorization requests for the remaining states and territories on November 17, 2020.
  • Nationwide
  • Nationwide

HCPCS Codes

  • K0890, K0891, K0013
  • L5856, L5857, L5858, L5973, L5980, and L5987
  • Required HCPCS: K0813-K0829, K0835-K0843, K0848-K0864
  • E0193, E0277, E0371, E0372, and E0373

Requests Accepted From

  • A beneficiary or a DME supplier
  • A beneficiary or a DME supplier
  • A beneficiary or a DME supplier
  • A beneficiary or a DME supplier

Decisions

  • 30 calendar days
  • Initial and subsequent request: 10 business days
  • Expedited Request: 2 business days
  • Initial Request: 10 business days
  • Subsequent Request: 10 business days
  • Expedited Request: 2 business days
  • Initial Request: 5 business days
  • Subsequent Request: 5 business days
  • Expedited Request: 2 business days

PA Decision Letter Recipients

  • Supplier
  • Supplier
  • Beneficiary or physician, if specifically requested
  • Supplier
  • Beneficiary or physician, if specifically requested
  • Supplier
  • Beneficiary or physician, if specifically requested

Resubmissions

  • One resubmission may be requested in a six-month period
  • Unlimited
  • Unlimited
  • Unlimited

Payments

Voluntary program.

An affirmed ADMC decision means beneficiary meets medical necessity requirements for Medicare

An affirmed ADMC is valid for six months from date of the decision

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
  • Claims from Representative Payees for Phase 1 only

Note: Claims from Representative Payees will only be excluded for PA programs that are not implemented on a national level. Before submitting a PAR, suppliers should verify if the beneficiary has a rep payee on file. Once the PA program becomes national, this exclusion will not apply.

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

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

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)
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