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June 22, 2022

Prior Authorization Request Form for OPD Procedures

A prior authorization request form is required for those designated services listed in the OPD Operational Guide. Hospital outpatient departments are responsible for ensuring a prior authorization request form has been submitted.

A New Field on the Form for the Provider

Many physicians' offices complete the prior authorization request form on behalf of the hospital OPD. The hospital OPD fax number is still required. You may now also include a valid fax number for the attending physician/practitioner on the form.

Benefits of the new field:

  • Physicians' offices will also receive a copy of the decision letter that is sent to the hospital OPD
  • Improves collaboration between the hospital OPD and the physician/practitioner
  • PAR decisions are received on a timely basis
  • Have a copy of the letter for the medical record

Completing the Form

  • On the CGS Medicare website, click on the section titled Forms
  • Click on Medical Review (Prior Authorization)
  • Select the procedure needing the prior authorization – a browser tab opens at the top
  • In the internet browser, complete the PDF form by typing on it and/or selecting from the dropdown choices
  • Provide the anticipated dates of service – this does not have to be the actual date
    • These dates can be changed if it is within the 120-day time frame from receiving the affirmed decision
  • Select the appropriate HCPC code or codes from the drop-down choices on the form
  • Fill out the form completely
  • At the top of the browser tab, you can click on the print Icon to print your completed form
    • Do not save or download the form to be reused
    • Form on the website is current and up to date. Bar code on the form will be processed appropriately and avoid misdirection.

It is highly recommended to type on the form versus completing it by hand. Handwriting can be illegible and not easily understood by the system thus causing delays in processing the prior authorization request.

Submit the Form

Be sure to submit a completed legible form through fax, mail, or esMD with the appropriate documentation for the procedure being requested. The form can also be completed and submitted through the myCGS portal along with uploading the appropriate documentation.


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