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OPD Prior Authorization Process

The prior authorization program applies to certain hospital outpatient department (OPD) servicesExternal PDF rendered on or after July 1, 2020. Any Part A hospital outpatient (TOB 13X) claim submitted for one of these services without a prior authorization determination and a corresponding unique tracking number (UTN) will be automatically denied.

Submitting a Prior Authorization Request (PAR)

Before the service is rendered, and before the claim is submitted for payment, the hospital OPD provider must submit the PAR. The PAR must include all documentation necessary to show the service meets applicable Medicare coverage, coding, and payment rules.

Note: An expedited review of a PAR may be requested when the beneficiary's life, health, or ability to regain maximum function is in jeopardy.


  • Submit the PAR by accessing the Forms web page and selecting the appropriate form. Note: If using myCGS (the preferred method) to submit the PAR, the forms are available in myCGS.
  • The PAR can be submitted by the following methods:

    myCGS:
    (Preferred Method)

    Access the myCGS web page for additional information.

    Fax:

    1.615.782.4486

    Electronic Submission of Medical Documentation (esMD):

    Refer to the esMD OverviewExternal Website web page on the CMS website.

    U.S. Mail:

    Mailing Address:
    CGS Administrators, LLC
    J15 Part A Prior Authorization Requests
    PO Box 20203
    Nashville, TN 37202

    FedEx/UPS/Certified Mail (Physical Address):
    CGS Administrators, LLC
    J15 Part A Prior Authorization Requests
    26 Century Blvd STE ST610
    Nashville, TN 37214-3685

PAR Review Types and Timeframes

  • CGS will review the PAR and issue a decision (affirmative or non-affirmative) within the following timeframes.

    Initial Submission

    The first PAR submitted. CGS will complete its review and send an initial decision letter within 10 business days of the receipt of the initial request.

    Resubmission

    A subsequent PAR, submitted with additional/updated documentation after the initial PAR was non-affirmed. CGS will review and send a decision within 10 business days of the receipt of the resubmission request.

    Expedited

    A PAR submitted when the beneficiary's life, health, or ability to regain maximum function is in jeopardy. If CGS substantiates the need for an expedited decision, CGS will make reasonable efforts to communicate a decision within 2 business daysof receipt of the expedited request.

A unique tracking number (UTN) will be assigned with each PAR. PAR decisions and UTNs are valid for 120 days (the decision date is counted as day 1).

PAR Decisions and Notification

CGS will send a provisional affirmation or non-affirmation decision with the UTN to the requester within the timeframes described above. A copy of the decision letter will also be sent to the beneficiary. CGS may send a copy of the decision to the requester via fax if a valid fax number was provided, even if the submission was sent via mail. Decision letters sent via esMD are not available at this time.

  • Affirmation – A provisional affirmation will be issued to the provider if it is decided that applicable Medicare coverage, coding and payment rules are met.
  • Non-Affirmation – A non-affirmation will be issued to the provider if it is decided that applicable Medicare coverage, coding and payment rules are not met. CGS will provide detailed information about all missing and/or non-compliant information that resulted in the non-affirmative decision.
    • If the PAR is non-affirmed, you may resubmit the PAR with additional supporting information, an unlimited number of times.
    • If you choose not to resubmit, and perform the service(s), and bill the claim, the service(s) will be denied. Once the claim is denied, you may request a Redetermination, the first level of appeal.

Note: The resubmission of the PAR should contain an exact match of the beneficiary's first name, last name, date of birth to the previous submission, and the UTN associated with the previous submission.


Claim Submission

  • The UTN, which is provided in the provisional affirmation or non-affirmation decision letter must be submitted on the claim.
    • For electronic claims, report the UTN in positions 1 through 18 (in the second treatment authorization field (Loop 2300, REF/G1/02)). When the claim enters the Fiscal Intermediary Shared System (FISS), the UTN will move to positions 19 through 32 and zeros will autofill the first field.
    • For all other claim submissions, you must TAB to the second field of the treatment authorization field and key the UTN.

Posted: 06.16.20

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