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Condition of Payment Prior Authorization (PA) Program: K0856 – Group 3 Single Power Option and K0861 – Group 3 Multiple Power Option Power Wheelchairs

Effective July 3, 2017, Durable Medical Equipment Medicare Administrative Contractors (DME MACs) began accepting Prior Authorization Requests (PAR) for the K0856 – Group 3 standard, single power option and K0861 – Group 3 standard multiple power option wheelchairs for dates-of-delivery on or after July 17, 2017 Nationwide and March 20,2017 for eligible for Medicare beneficiaries residing in New York (Jurisdiction A – Noridian), Illinois (Jurisdiction B – CGS), West Virginia (Jurisdiction C – CGS) and, Missouri (Jurisdiction D – Noridian).

A Condition of Payment Prior Authorization Request  may be submitted by either the treating physician/practitioner or the supplier. Before sending the request, the submitter should complete a Condition of Payment Prior Authorization Request CoversheetPDF. The PAR must include the following documentation:

  • Completed PAR coversheet,
  • 7-element written order,
  • Treating physician/practitioner face-to-face assessment,
  • Detailed product description,
  • Specialty evaluation (if required by policy); and
  • Other relevant medical documentation.

Please note:  A provisional affirmation prior authorization decision is a condition of payment.  CMS is finalizing the provision to automatically deny payment for a claim for an item on the Required Prior Authorization List that is submitted without a provisional affirmation prior authorization decision. 

The request may be mailed or faxed as follows:

Fax the Condition of Payment Program Coversheet  to:

615-664-5960

Mail the Condition of Payment Program Coversheet  to:

CGS – JUR C DME Medical Review – Condition of Payment Program
PO Box 24890
Nashville, TN 37202-4890

After receipt of all relevant documentation, CGS will review and communicate a decision within 10 business days. The decision letter regarding prior authorization (affirmative or non-affirmative) will be sent to the supplier and the Medicare beneficiary. In the event of a non-affirmative decision, the letter will explain why the PAR was not affirmed. The letter will additionally provide a prior authorization tracking number that should be submitted with the PMD claim.

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