January 12, 2023
Who Will Need to Submit a Prior Authorization Request for HOPD Services?
A Notice of Withdrawal of Exemption from Prior Authorization notification letter was sent to providers currently exempt; but unable to maintain a compliance threshold of 90% or greater. The providers receiving this notification letter will need to submit request for prior authorization.
Beginning December 18, 2022, providers in the following categories will be required to submit a prior authorization request for certain hospital outpatient department services starting January 1, 2023:
- Providers who have withdrawn from the provider exemption list
- Exempt providers who did not achieve a 90% threshold after a review of claims
- Exempt providers who requested to be withdrawn from the list
- Providers who did not achieve a 90% affirmation rate for prior authorization requests submitted for the year
When submitting a prior authorization request providers will need to:
- Review the process for submitting a prior authorization request
- Become familiar with the requirements for each service category
- Review the HCPC codes which require prior authorization
- Provide medical documentation to support medical necessity
- Complete a prior authorization request form with all the appropriate information
- Use the current form for the specific service category
- My CGS Portal members can complete a request form online
- Submit the prior authorization with all appropriate documentation via fax, mail, or esMD
- Allow enough time for processing and review of requests
Prior authorization is a condition of payment. Procedures performed without a prior authorization may result in a denied claim.
Resources
Join Electronic Mailing List
Print
Bookmark
Email
Facebook
YouTube
LinkedIn
CGS Medicare Mobile App