About Hospital OPD PA Model
Table of Contents
About Hospital OPD PA Model
The CMS is implementing a prior authorization program for certain hospital OPD services for DOS on or after 7/1/2020. CMS believes prior authorization for certain hospital OPD services will ensure that Medicare beneficiaries continue to receive medically necessary care while protecting the Medicare Trust Fund from improper payments and keeping the medical necessity documentation requirements unchanged for providers. As a condition of payment for DOS on or after 7/1/2020, a PAR is required for the following hospital OPD services:
- Blepharoplasty, eyelid surgery, brow lift and related services
- Botulinum toxin injections
- Panniculectomy, excision of excess skin and subcutaneous tissue (including lipectomy) and related services
- Rhinoplasty and related services
- Vein ablation and related services
CMS has added two new services to the hospital OPD Prior Authorization program. For dates of service beginning on or after 7/1/2021, the additional hospital OPD services will be required as a condition of payment. These services are:
- Cervical Fusion with Disc Removal
- Implanted Spinal Neurostimulators
Facet joint interventions are added to the hospital OPD services that require prior authorization as a condition of payment. Requests may be submitted starting on 6/15/2023 for dates of service rendered on or after 7/1/2023.
You can use the Prior Authorization HCPCS Code Inquiry Tool to verify if an HOPD procedure code requires PA. If the procedure code is not found on the HCPCS Code Inquiry Tool, a PA is not required.
General Information
| Question | Description |
|---|---|
| WHO | Hospital OPD when rendering certain OPD services for Medicare beneficiaries that bill Medicare Part A can receive prior authorization. |
| WHAT | The hospital OPD (or requestor) will be responsible for submitting a PAR and all required documentation for eight groups of cosmetic services and their related services prior to the services being rendered to Medicare beneficiaries and before the provider can submit claims for payment under Medicare for these services. The eight groups of 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 will apply to hospital OPD services rendered on or after 7/1/2020. |
| WHERE | The program applies to all jurisdictions. |
| WHY | CMS believes PA for certain hospital OPD services will ensure that Medicare beneficiaries continue to receive medically necessary care while protecting the Medicare Trust Fund from improper payments with no change in medical necessity documentation requirements. It is designed to ensure all relevant coverage, coding, payment rules and medical record requirements are met before the service is rendered to the beneficiary and the claim is submitted for payment. |
| HOW | Submit the PAR and all documentation requirements specific for the procedure type requested. A UTN will be assigned to each PAR that receives a clinical decision of Provisional Affirmation, Non-Affirmation or Provisional Partial Affirmation. The standard time frame to review and communicate a decision for all initial and resubmitted requests is ten (10)-business days from the date of receipt. The Provisional Affirmation UTN will have a validation period of 120-days. The decision date shall be counted as the first day of the 120 days |
Related Content
- OPD Operational Guide
- Guidelines for Submitting Prior Authorization Certain Hospital Outpatient Department
- OPD Frequently Asked Questions
- OPD Open Door Forum Slides 05-28-2020
- Prior Authorization for Certain Hospital Outpatient Department (OPD) Services | CMS
Please share your thoughts about your experience with our Prior Authorization process.
Revised 6/13/2023