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OPD Prior Authorization

OPD Prior Authorization

The Centers for Medicare & Medicaid Services (CMS) established a nationwide prior authorization (PA) process as a condition of payment for certain hospital outpatient department (OPD) services. Effective for dates of service July 1, 2020, Part A hospital OPDs must submit a prior authorization request (PAR) and supporting documentation to their Medicare Administrative Contractor (MAC) and receive a decision before rendering the service and submitting a claim for processing.

OPD Services/HCPCS Codes

How to Submit a Prior Authorization Request

  • Who is Responsible for Submitting a PAR?

    The OPD PA process applies to Part A hospital OPDs that submit claims with Type of Bill (TOB) 13X and are paid under the Outpatient Prospective Payment System (OPPS). Since the PA process is a condition of payment for the hospital service(s), the Part A hospital OPD is responsible for ensuring that a PAR is submitted.

    NOTE: Although other providers, such as a physician/staff may submit a PAR on the hospital OPD's behalf, departmental collaboration is crucial. Please reference the Authorization Process section below for additional information.

  • When Should a PAR Be Submitted?

    A PAR must be submitted prior to rendering the service and submitting a claim for processing. In addition, please plan and allow the allotted timeframe for a decision (10 business days for initial/resubmission requests or 2 business days for expedited requests). Please reference the Authorization Process section below for additional information.

    NOTE: A PAR is valid for one claim/date of service.

  • What Must Be Submitted?

    CMS does not require a specific form to request prior authorization; however, completing the request in myCGS or by utilizing the CGS service-specific PAR form(s) will help to ensure all required data elements are included and avoid any rejections and/or delays in processing.

    In addition, any medical record documentation to support that the service was medically reasonable and necessary and meets all applicable Medicare coverage, coding and payment rules is required. Please reference the Medical Record Documentation section below for additional information.

  • How/Where Should a PAR Be Submitted?

    A PAR may be submitted using one of the following methods:

Medical Record Documentation

To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for the service(s). General documentation requirements for each service that requires prior authorization are listed below. In addition, providers should reference any CGS Local Coverage Determination (LCD) / Local Coverage Article (LCA), where applicable. In the absence of an LCD/LCA, CGS utilizes CMS-based regulatory guidance, National Coverage Determinations (NCDs), evidence-based specialty guidelines and accepted standards of care, and high level, high quality published literature to establish medical necessity

NOTE: CGS is not able to accept any of the following in place of medical record documentation: a physician letter of medical necessity, written comments of medical necessity within the PAR, documentation that does not contain medical credentials, or generic statements.

Authorization Process

CGS will review the information submitted with the PAR, issue a decision (affirmative or non-affirmative) and assign a Unique Tracking Number (UTN).

  • Request Types and Timeframes

    When submitting a PAR, it is important to select the appropriate request type and allow the allotted timeframe for CGS to issue a decision as outlined below.

    Request Type Description Review Decision Timeframe
    Initial

    First PAR submitted for this beneficiary/date of service

    NOTE: A PAR is valid for one claim/date of service.

    10 business days
    Resubmission

    Any subsequent PAR submitted to correct an error or omission after the initial PAR was non-affirmed. A provider may resubmit a PAR an unlimited number of times.

    NOTE: Ensure the most recent UTN is reported with each resubmission request.

    10 business days
    Expedited

    A request for a PAR decision to be performed on an accelerated timeframe because delays in review and response could jeopardize the life or health of the beneficiary ONLY.

    NOTE: Do not select this request type based solely on the scheduled date of service for a procedure. The specific reason/rationale must be included for CGS to substantiate the need for an expedited decision.

    2 business days
  • Decision Letter(s)

    CGS will send a decision letter with the UTN to the requester using the method the PAR was received. CGS also has the option to send a copy of the decision letter via FAX if a valid FAX number is provided with the PAR (even if the PAR was submitted via a method other than FAX). A copy of the decision letter will also be sent to the beneficiary.

    NOTE: While the OPD PA process is a condition of payment for the Part A hospital OPD service(s), a PAR may be submitted by other providers, such as a physician/staff on behalf of the hospital OPD. The requester is responsible for ensuring the decision/UTN is communicated to the appropriate provider(s). Inquiries related to a PAR status/decision cannot be addressed via the Provider Contact Center (PCC) or the Medical Review department.

  • Decisions

    A valid PAR will result in one of the following decisions. A PAR decision/UTN is valid for 120 days from the date of the decision letter.

    Decision

    Description

    Provisional Affirmation

    A preliminary finding that a future claim submitted to Medicare for the service(s) likely meets Medicare's coverage, coding and payment requirements

    Non-Affirmation

    A preliminary finding that if a future claim is submitted to Medicare, the requested service does not likely meet Medicare's coverage, coding and payment requirements

    NOTE: CGS will provide detailed information about all missing and/or non-compliant information that resulted in the non-affirmative decision. A resubmission request may be submitted with additional/updated documentation an unlimited number of times until a provisional affirmation decision is received.

    Provisional Partial Affirmation

    One or more service(s) on the PAR received a provisional affirmation decision and one or more service(s) received a non-affirmation decision

Exemption Process

Hospital OPDs who submit PARs will be assessed on a semi-annual basis and those who demonstrate compliance with Medicare coverage, coding, and payment rules related to the prior authorization program are eligible for exemption.

Exemption Timeline

Cycle 1

May 1 – November 1

Cycle 2

November 1 – May 1

February 1

CGS calculates the affirmation rate of initial PARs sent September 1 and after.

Providers who submit at least 10 PARs and achieve a provisional affirmation threshold of at least 90% are eligible for exemption.

August 1

CGS calculates the affirmation rate of initial PARs sent May 1 and after.

Providers who submit at least 10 PARs and achieve a provisional affirmation threshold of at least 90% are eligible for exemption.

March 1

Exempt providers receive a Notice of Exemption letter 60 days prior to the exemption cycle start date.

September 1

Exempt providers receive a Notice of Exemption letter 60 days prior to the exemption cycle start date.

May 1

The exemption cycle begins. Exempt providers should not submit PARs.

November 1

The exemption cycle begins. Exempt providers should not submit PARs.

September 30

Exempt providers will receive an Additional Documentation Request (ADR) for a 10-claim sample from the exemption period to determine continued compliance. *

April 2

Exempt providers will receive an Additional Documentation Request (ADR) for a 10-claim sample from the exemption period to determine continued compliance. *

On or before December 17

Providers will receive a Notice of Exemption or Notice of Withdrawal of Exemption letter.

Providers who continue to demonstrate a 90% or greater claim approval rate for the 10-claim postpayment review will remain exempt and do not need to submit PARs.

On or before June 19

Providers will receive a Notice of Exemption or Notice of Withdrawal of Exemption letter.

Providers who continue to demonstrate a 90% or greater claim approval rate for the 10-claim postpayment review will remain exempt and do not need to submit PARs.

February 15

Providers who did not meet the 90% claim approval rate for the 10-claim postpayment review will no longer be exempt and are required to submit PARs.

August 18

Providers who did not meet the 90% claim approval rate

for the 10-claim postpayment review will no longer be exempt and are required to submit PARs.

March 1

Providers who are no longer exempt must have PAR for any claim submitted on or after this date.

September 1

Providers who are no longer exempt must have PAR for

any claim submitted on or after this date.

* Hospital OPDs have 45 days to respond to the ADR and CGS will complete the review within 30 days of receipt of the requested documentation. Additional documentation submitted after the initial 45-day response timeframe will not change the provider compliance rate if CGS has already finalized it and sent notification. CGS will still review late documentation, issue a determination, and make a claim adjustment, if necessary. Claim denials are subject to the normal appeals process; however, overturned appeals will not change the OPD's exemption status.

Additional information is available in the Exemption Article.

Claim Submission

  • Unique Tracking Number (UTN)

    The UTN included in the decision letter should only be reported on the Part A hospital OPD (TOB 13X) claim.

    • For electronic claims, report the UTN in positions 1–18 of the Treatment Authorization Field (loop 2300 REF02 (REF01=G1) segment).
    • For all other submissions, TAB to the second Treatment Authorization Field and key the UTN.
  • Affirmed PA Decision on File

    If the UTN reported on a claim is associated with a provisional affirmation decision, including any service(s) that was part of a partially affirmed decision:

    • The claim will likely be paid if all Medicare coverage, coding and payment requirements are met.
    • The claim may be denied based on either of the following:
      • Technical requirements that can only be evaluated after the claim has been submitted for formal processing
      • Information not available at the time of the PAR
    • The claim will be afforded some protection from future audits (pre- and postpayment); however, review contractors may audit claims if potential fraud, inappropriate utilization or changes in billing patterns are identified.
  • Non-Affirmed PA Decision on File

    If the UTN reported on a claim is associated with a non-affirmation decision, including any non-affirmed service(s) that was part of a partially affirmed decision:

    • The claim will be denied.
    • All appeal rights are then available.

      NOTE: The prior authorization process is a condition of payment. As the term suggests, a condition of payment is a rule, regulation, or requirement that must be met in order for a provider to lawfully request and receive reimbursement from Medicare.
    • The claim may then be submitted to secondary insurance, if applicable.
  • No PA Decision on File

    If a UTN is not reported on a claim for a service that requires prior authorization:

    • The claim will be automatically denied.
    • All appeal rights are then available.

      NOTE: The prior authorization process is a condition of payment. As the term suggests, a condition of payment is a rule, regulation, or requirement that must be met in order for a provider to lawfully request and receive reimbursement from Medicare.
    • If a HCPCS code that requires PA is reported with modifier GA (Advance Beneficiary Notice of Noncoverage (ABN) issued), the claim will suspend and an Additional Documentation Request (ADR) letter will be sent to the provider. CGS will perform a review to determine the validity of the ABN following standard claim review guidelines and timelines outlined in the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 30External PDF, § 40.
  • Denials for Related Services

    Claims related to or associated with services that require PA as a condition of payment will not be paid, if the service requiring PA is not also paid. These related services include, but are not limited to, services such as anesthesiology services, physician services, and/or facility services. Only associated services performed in the OPD setting will be affected.

    Depending on the timing of claim submission for any related services, claims may be automatically denied or denied on a postpayment basis.

    The OPD PA Part B Associated Codes List is located in Appendix B of the CMS OPD Operational GuideExternal pdf.

  • Claim Exclusions

    The following claim types are excluded from the PA program:

    • Veterans' Affairs
    • Indian Health Services
    • Medicare Advantage
    • Part A and Part B Demonstration
    • Medicare Advantage IME only claims
    • Part A/B Rebilling
    • Claims for Emergency Department services when the claim is submitted with modifier ET or revenue code 045X.
      • NOTE: This does not exclude these claims from regular medical review.

Appeals

Claims subject to PA requirements under the hospital OPD program follow all current appeals procedures. A PAR that is non-affirmed is not an initial determination on a claim for payment for services provided and, therefore, would not be appealable; however, the provider has an unlimited number of opportunities to resubmit a PAR, provided the claim has not yet been submitted and denied.

A non-affirmation PA decision does not prevent the provider from submitting a claim. Submission of such a claim and resulting denial would constitute an initial payment determination, which makes the appeal rights available.

NOTE: The prior authorization process is a condition of payment. As the term suggests, a condition of payment is a rule, regulation, or requirement that must be met in order for a provider to lawfully request and receive reimbursement from Medicare.

For additional information, please reference the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 29External PDF.

CGS Resources

CMS Resources

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