OPD Facility/Physician Communication
What does this mean for the Part B Provider who will be performing the service in the hospital OPD?
As the performing provider, it is up to you to work with the staff at the hospital OPD department so that they may obtain the prior authorization for the services you want to perform in the OPD.
The PAR will require the medical necessity information which is typically documented in the patient’s medical record; documentation must fully support medical necessity for the service being performed. Since the physician typically holds the patient’s medical record, it is imperative that Part B providers work closely with the OPD to ensure they have all of the necessary information to obtain the PAR prior to rendering services which require prior authorization.
While only the hospital OPD service requires prior authorization, CMS reminds providers who perform services in the hospital OPD setting that claims related to or associated with these services will not be paid if the service requiring prior authorization is not eligible for payment. These related services include, but are not limited to, anesthesiology services, and physician services. Only associated services performed in the OPD setting are affected. These services, if performed without the required prior authorization, may be automatically denied or denied on a post-payment basis.
Decisions for PAR requests:
- Provisional affirmation
- Preliminary finding that future claims submitted to Medicare for the service likely meets Medicare’s coverage, coding, and payment requirements
- Nonaffirmation
- Preliminary finding that future related claims for the intended service does not meet Medicare’s coverage, coding, and payment requirements
- Provisional partial affirmation
- Preliminary finding that one or more service(s) on the request received a provisional affirmation decision, and one or more service(s) on the request received a non-affirmation decision
The hospital OPD and beneficiary will receive the decision letter from the MAC. Physicians or other practitioners who provide related services in the hospital OPD for the procedure requiring prior authorization may obtain a copy of the decision letter from the OPD.
Physician claims do not require a prior authorization number. The hospital OPD claim does require a unique tracking number which is provided upon the decision for prior approval.
Please share your thoughts about your experience with our Prior Authorization process.