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CGS Administrators, LLC

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Prior Authorization

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

PMD Condition of Payment Required Prior Authorization Program

CMS has added an additional seven PMD codes to the required prior authorization process K0857-K0860 and K0862-K0864 All new rental series claims for these PMDs nationwide 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. CGS will begin accepting requests for the affected codes on July 08, 2019.

Group 2 PRSS Condition of Payment Required Prior Authorization Program

CMS is adding 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. Prior authorization for PRSS will be implemented in two phases.

Phase I began July 22, 2019 for beneficiaries residing in California, Indiana, New Jersey, and North Carolina. CGS will begin accepting requests for the affected codes on July 08, 2019.

Phase II will expand prior authorization of these codes to the remaining states and territories October 21, 2019. CGS will begin accepting requests for the affected codes on October 07, 2019.
  ADMC PMD Condition of Payment PA Program PRSS Condition of Payment PA Program

States

  • Nationwide
  • Nationwide
  • California, Indiana, New Jersey, and North Carolina – Required as of July 22, 2019
  • Nationwide – Required as of October 21, 2019

HCPCS Codes

  • PMDs Eligible for ADMCas of July 08, 2019 K0890, K0891, K0013
  • Required as of July 22, 2019 K0857-K0860 and K0862 – K0864
  • Required HCPCS: K0813-K0829, K0835-K0843, K0848-K0856, and K0861
  • 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

Decisions

  • 30 calendar days
  • Initial Request: 10 business days
  • Subsequent Request: 20 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

Resubmissions

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

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)
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