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Prior Authorization: ASC

Ohio Part B users can access this form. Use the PA ASC form to request prior authorization for items or services subject to the Prior Authorization Demonstration for Certain Ambulatory Surgical Center (ASC) Services.

ASC Form

  1. Select ‘Forms’.
  2. Select ‘Prior Authorization’ from the ‘Select a Topic’ drop-down menu.
  3. Select ‘PA ASC from the ‘Select a Type’ drop-down menu.
  4. Click the link to open the form.

ASC Name

The ASC Information fields auto-populate based on the user ID used to log in and can't be edited. If you can't log in with an ASC account, please fax your request.

ASC Details

Request Details

Select the appropriate request type:

  • Initial Request (first request for this beneficiary and date of service)
  • Resubmission Request (subsequent request after receiving a non-affirmation decision)
  • If you need the request expedited, check box.

Requestor/Beneficiary Info

Requestor Information

This section describes the person who should receive the prior authorization decision. Report the following:

  • First Name
  • Last Name
  • Email
  • Phone Number
  • Extension (if applicable)
  • Send decision by fax (check box, if applicable)

Beneficiary Information

This section describes the patient who will receive the items or services. Report the following (as it appears on the current Medicare card):

  • Medicare ID
  • First Name
  • Last Name
  • Date of Birth

You may use the ‘Validate Beneficiary’ button to verify that the information you enter matches the eligibility file.

Validate

Performing Surgeon Information

This section describes the physician who will provide the item or service. Report the following:

  • First Name
  • Last Name
  • NPI
  • Fax Number (optional; the prior authorization decision will be faxed to this number)
  • Address (optional; the prior authorization decision will be mailed to this address)

Services Requested

This section describes the ASC services for which you’re requesting prior authorization. Report the following:

  • Choose the appropriate option from the 'Select a Service' drop-down menu.

Service

  • CPT/HCPCS Codes
    • Key 1 CPT/HCPCS code; click ‘Add’.
    • You may add up to 4 codes.
  • Primary Diagnosis
  • Secondary Diagnosis (if applicable)
  • Date of Service
  • Answer each question under Service-Related Questions.

Attachments

Attachments

You must attach at least 1 PDF document (up to 40 MB). The total size for all attachments can’t exceed 150 MB.

Select ‘Choose File’. Follow the prompts to locate and attach your document(s).

Review and Sign

Submit

When ready, click ‘Submit’. 

Please make sure you are signed in with an ASC account. 

If you are not, please submit your request via fax.

The e-Signature box will display. First, review to ensure all required fields and attachment(s) are complete and correct.

  • If satisfied, select ‘Ok’.
  • If not, select ‘Cancel’ to make any corrections to the form or attachment(s).

Messages

Go to ‘Messages’ to view the following notifications in your Message Inbox:

  • After you submit the form, myCGS will deliver a message with your request details (confirmation).
  • Once the review is complete, you’ll receive a decision letter.

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