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PA

Prior Authorization Process

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

OPD Services (HCPCS Codes)

See the Final List of Outpatient Services That Require Prior AuthorizationExternal PDF.

Prior authorization is a condition of payment. Claims submitted for services rendered without a provisional affirmation PAR decision may receive a denial.

Request Types & Timeframes

When submitting a PAR, select the appropriate request type and allow the allotted timeframe for CGS to issue a decision.

Request Type Description Review Decision Timeframe

Initial

First PAR submission for this beneficiary/date of service.

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

7 calendar days

Resubmission

Any subsequent PAR submission (i.e., to correct an error or omission after receiving a non-affirmation decision for an initial PAR). Providers have an unlimited number of opportunities to resubmit a PAR.

NOTE: Report the most recent UTN with each resubmission request.

7 calendar days

Expedited

Used ONLY when a delay for a decision could seriously jeopardize the beneficiary's life, health or ability to regain maximum function.

NOTE: Don't select this request type based solely on the scheduled procedure date. When appropriate, you must include the specific reason/rationale 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 (via the same method used to submit the PAR)
  • A fax number provided in the PAR (optional)
  • The beneficiary

NOTE: While the prior authorization process applies to hospital OPDs, CMS allows a physician or practitioner to submit a PAR on the hospital OPD's behalf. The requester is responsible for communicating the decision/UTN to the appropriate provider(s).

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 a future claim submitted to Medicare for the requested service does not likely meet Medicare's coverage, coding and payment requirements.

NOTE: CGS will provide an explanation for a non-affirmative decision. You may submit a resubmission request with additional/updated documentation until you receive a provisional affirmation decision.

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.

How to Submit a Prior Authorization Request

Who is Responsible?

The prior authorization process applies to, and is a condition of payment for, hospital OPDs. CMS allows a physician or practitioner to submit a PAR on the hospital OPD's behalf. The requester is responsible for communicating the decision/UTN to the appropriate provider(s).

When to Submit?

Submit a PAR before you furnish the service and submit a claim to Medicare. In addition, please plan and allow the allotted timeframe for a decision (7 calendar days for initial/resubmission requests or 2 business days for expedited requests).

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

What to Submit?

CMS doesn't require a specific form. To help ensure you include all required data elements, and to avoid a rejection or processing delays, we recommend using the following:

  • myCGS portal

    NOTE: This option is only available when you sign in with a user ID registered to a Part A NPI/PTAN.

  • OPD Prior Authorization Request Forms

    NOTE: Access the form from our website for each request. Don't save forms to your computer for future use.

Also include medical record documentation to support that the service is medically reasonable and necessary and meets all applicable Medicare coverage, coding and payment rules.

How to Submit?

Use one of these methods to submit a PAR:

Claim Submission

Unique Tracking Number (UTN)

Report the UTN on the Part A hospital OPD (TOB 13X) claim only.

  • 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 corresponds with a provisional affirmation decision, including any service(s) that was part of a partially affirmed decision, the claim:

  • Will likely pay if all Medicare coverage, coding and payment requirements are met.
  • May deny based on either of the following:
    • Technical requirements that are only evaluated after claim submission
    • Information not available at the time of the PAR
  • Is 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 corresponds with a non-affirmation decision, including any non-affirmed service(s) that was part of a partially affirmed decision:

  • The claim will deny.
  • All appeal rights are then available.

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

  • You may then submit the claim to secondary insurance, if applicable.

No PA Decision on File

Claims for a service that requires prior authorization without a UTN:

  • Will automatically deny.
  • All appeal rights are then available.

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

  • If a HCPCS code that requires prior authorization is reported with modifier GA (Advance Beneficiary Notice of Noncoverage (ABN) issued), the claim will suspend, and the provider will receive an Additional Documentation Request (ADR) letter. Upon receipt of the requested documentation, CGS will perform a review to determine the validity of the ABN. See the 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

Related services include, but aren't limited to, associated anesthesiology, physician, and/or facility services performed in the OPD setting. See Appendix B – OPD PA Part B Associated Codes ListExternal PDF.

Claims for related or associated services may automatically deny, or deny on a postpayment basis, when OPD services that require prior authorization as a condition of payment receive a non-affirmation decision and/or claim denial.

Claim Exclusions

Claim types excluded from the prior authorization program include:

  • Veterans' Affairs
  • Indian Health Services
  • Medicare Advantage
  • Part A and Part B Demonstration
  • Medicare Advantage IME only claims
  • Part A/B Rebilling
  • Emergency Department services (claims submitted with modifier ET or revenue code 045X)
    • NOTE: This doesn't exclude these claims from regular medical review.

Appeals

Claims subject to prior authorization requirements under the hospital OPD program follow all current appeals procedures. A non-affirmed PAR decision isn't appealable since it's not an initial determination on a claim for payment for services provided. Providers have an unlimited number of opportunities to resubmit a PAR before submitting a claim.

A non-affirmation decision doesn't prevent the provider from submitting a claim. Submission of such a claim and resulting denial does 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 rule, regulation, or requirement must apply for a provider to lawfully request and receive reimbursement from Medicare.

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

Updated: 12.31.2024

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