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June 17, 2020 - Updated 07.10.20

Using myCGS to Obtain Prior Authorization (PA) for Certain Hospital Outpatient Department (OPD) Services

As a result of the Calendar Year 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule 1717-FExternal PDF, CMS implemented a prior authorization process for certain services provided in the outpatient department of the hospital.  This includes:

  • Blepharoplasty
  • Botulinum Toxin Injections
  • Panniculectomy
  • Rhinoplasty
  • Vein Ablation
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Check the Final List of Outpatient Services that Require Prior AuthorizationExternal PDF for applicable CPT/HCPCS codes

PA is a process through which a request for provisional affirmation of coverage is submitted for review BEFORE a service is furnished to a Medicare patient and before a claim is submitted for payment. It helps to ensure that all applicable Medicare coverage, payment, and coding rules are met before a service is furnished.

This program will apply to hospital OPD services rendered on or after July 1, 2020. We will begin accepting PA requests on June 17, 2020.

For your convenience, you may use myCGS to submit PAs for OPD services!


Once logged into myCGS, select the FORMS tab.

  • Under the "Select a Topic" drop-down box, click "Prior Authorization."
  • The "Select a Type" drop-down will default to "PA OPD."
  • Select the "PA OPD: PA-J15-A-1000" link at the bottom of the page.

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Once the PA form loads you will find several sections requiring your attention. Regardless of the service for which a prior authorization request (PAR) is submitted, the form sections include Provider Information, Request Details, Requestor Information, Beneficiary Information, and Attending Physician Information. Details of these section are identified below:

Provider Information

This section will auto-populate with information specific to your myCGS ID and provider information. No changes can be made to the Provider Information section.

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Request Details

Select whether this is an initial or resubmission request.

  • Initial Request: The first prior authorization request (PAR) sent to us for review and decision. We will review attached medical records and send an initial decision letter that is either postmarked or faxed within 10 business days following the receipt of the initial request.
  • Resubmission Request: Subsequent PAR resubmissions to correct an error or omission identified after a PA decision has been made by CGS. Resubmissions include additional/updated documentation after the initial PAR was non-affirmed. We will postmark or fax notification of the decision of these resubmitted requests to the provider or beneficiary (if specifically requested by the beneficiary) within 10 business days of receipt of the resubmission request.

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    • When a resubmission is requested, you must enter the 14-digit unique tracking number (UTN) assigned to the initial/previous PAR.  Click the "Get Previous Submission Information" so that details from the previous decision will display. Verify the UTN entered is correct and specific to your provider.

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  • · Expedited Request: You may submit a request for an expedited review of a PAR if delays in receipt of a PA decision could jeopardize the life or health of the beneficiary. Enter the reason and details for the expedited PA decision. Upon receipt, a decision will be made within 2 business days.

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Requestor Information

This section identifies your name, phone number, and email address associated with your myCGS user ID and will auto-populate. If you would like to receive your PAR decision via fax, check the box and enter your fax number.

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Beneficiary Information

Enter the beneficiary’s Medicare Beneficiary Identifier (MBI), name, date of birth, and gender. Once entered, click the "Validate Beneficiary" button. This will allow myCGS to check eligibility records to ensure the beneficiary information entered is correct.

NOTE: Be sure to verify the information is correct by referring to the beneficiary’s Medicare card.

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Attending Physician Information

Enter the name, National Provider Identifier (NPI), and complete address of the physician/non-physician practitioner (NPP) who has overall responsibility for the patient’s medical care and treatment.

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Services Requested

The "Services Requested" section of the form varies depending upon the type of service for the PAR.

On the "Select a Service" drop-down, click on the service for which the PAR is for. Doing this will allow additional fields to display that are needed in order for us to render a PA decision to you.

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  • Available fields:
    • HCPCS Code: Select the CPT code from the listing
    • Primary Diagnosis Code: Enter the primary diagnosis code
    • Secondary Diagnosis Code: Identify a second diagnosis code, if applicable
    • Related Codes: Enter any CPT/HCPCS codes related to those selected above
    • Dates of Service: Enter the date range for the service
    • Type of Bill: Identify the appropriate TOB applicable for this service
      • Part A hospital outpatient (TOB 13X)
    • Number of Units: Enter the number of units of the injection
      • Required only for Botulinum Toxin Injection PARs
  • Service Related Questions will display based upon the type of service. These questions will help support medical necessity and, depending upon your answer, note when the service is not medically necessary.

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Attachments

Documentation from the medical record to support medical necessity of the service is to be attached to the myCGS form. Attachments must be in a PDF format and no large than 40MBs. The total of all attachments cannot exceed 150MBs.

NOTE: You must attach at least one document. Please refer to the applicable Local Coverage Determination and/or Local Coverage Article for direction.

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Once the form is complete and all documentation attached, select "Submit" to send the PAR to CGS.

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An eSignature box will display. Click OK to confirm the request and to sign the form.

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NOTE: If you do not click OK to sign the form, it will not be sent.

Confirmation

Confirmation messages will be delivered to your Messages inbox. The message that includes a Submission ID may be used to check the status of the PAR by entering the Submission ID into the "Get Status" screen located on any tab throughout the portal.

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  • PAR statuses available:
    • Confirmed: The PAR has been received and successfully uploaded into our system.
    • Decision: A decision has been made on the PAR.  Refer to the PAR Decision Letter for affirmed/non-affirmed details.

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View PAR Decision Letter

The decision letters for PARs submitted through myCGS will be delivered to your myCGS Messages inbox (unless you request to receive it via Fax in the Requestor Information section above.)

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Click the link. A new window will open with a link to view the letter.

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The decision letter will open as a PDF document.

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NOTE: PAR decisions and UTNs are valid for 120 days (the decision date is counted as day 1).

Withdraw a PAR

If you submit a PAR and later determine that you need to withdraw the request, please send an email to J15APRIORAUTHEDUCATION@cgsadmin.com with “Cancellation Request” as the subject.

REFERENCE:

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