About Hospital OPD PA Model
Table of Contents
General Information
| Question | Description |
|---|---|
| WHO | It is the responsibility of the hospital OPD to submit all necessary documentation and secure PA; however, physician’s offices are permitted to obtain PA on behalf of the OPD. |
| WHAT | The hospital OPD PA program includes eight potentially cosmetic and/or high-volume services and their related services. The eight (8) hospital OPD services are blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, vein ablation, cervical fusion with disc removal, implanted spinal neurostimulators, and facet joint interventions. |
| WHEN | The program applies to hospital OPD services rendered on or after:
|
| WHERE | The program applies to Medicare Fee-For-Service beneficiaries and participating hospital OPDs in both Jurisdiction 6 and Jurisdiction K. |
| WHY | CMS believes that PA for specific hospital OPD services ensures Medicare beneficiaries receive medically necessary care while safeguarding the Medicare Trust Fund from improper payments. It maintains current documentation standards, ensuring compliance with all relevant coverage, coding, payment rules, and medical record requirements before service delivery and claim submission. |
| HOW | Submit the prior authorization request (PAR) with all procedure-specific documentation. Each PAR that receives a clinical decision—Provisional Affirmation, Non-Affirmation, or Provisional Partial Affirmation—will be assigned a Unique Tracking Number (UTN), which must be included on the OPD claim. The standard review and decision communication time frame for all initial and resubmitted requests is seven calendar days from receipt. A Provisional Affirmation UTN is valid for 120 days, with decision date counting as day one. |
- Utilize the Prior Authorization CPT/HCPCS Code Inquiry Tool to verify if an HOPD procedure code requires PA. If the code is not listed, PA is not required.
- When verifying Botox HCPCS codes, the pair requested must display a yes for both codes to qualify for PA.
- Refer to OPD Frequently Asked Questions #7 and #37 for permanent Implanted Spinal Neurostimulators.
Related Content
- OPD Operational Guide
- Guidelines for Submitting PA for Certain Hospital Outpatient Department Services
- OPD Frequently Asked Questions
- Prior Authorization for Certain Hospital Outpatient Department (OPD) Services | CMS
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Revised 6/23/2025