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Prior Authorization Outpatient Department Rejections Alert

National Government Services has seen a significant increase in rejections due to invalid information provided on PAR cover sheets.  

Please see the following for top reasons for rejections:  

  • No TOB code or invalid TOB provided
  • Missing paired botulinum procedure code
  • Invalid Part A PTAN/NPI combinations
    • ASC submissions (do not require PA)
  • Unsubstantiated expedite requests
  • HCPCS codes that do not require PA

Prior Authorization Reminders

  • TOB codes are not HCPCS codes. A TOB code identifies the type of bill that will be submitted on the claim by the HOPD.
  • Botulinum Toxin codes in conjunction/paired with procedure codes other than 64612 or 64615 do not require prior authorization under this program. Do not submit PARs with an unpaired code for NGSConnex cases.
  • Facility/provider types such as physician’s offices, critical access hospitals, or ASCs are not required to submit PARs.
  • Dates of service are not an appropriate reason to request an expedite review of a PAR. An expedited request is substantiated when the documentation provided supports that the standard timeframe could jeopardize the life or health of the beneficiary.
  • If the procedure code is not found on the HCPCS Code Inquiry Tool, or on the supplied NGS cover sheets, a PA is not required. In addition, if the NGSConnex drop down menu for HCPCS selection does not include the desired HCPCS code, PA is not required.  

Please contact HOPD billing to obtain the proper Part A PTAN/NPI combination and TOB code. Obtaining and providing this information upfront will significantly reduce the number of rejections received.

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Revised 7/18/2023