OPD Facility/Physician Communication
The implementation of the Outpatient Department (OPD) Prior Authorization (PA) program has specific implications for Part B physicians performing services within hospital OPDs.
Each prior authorization request (PAR) requires documentation from the beneficiary’s medical record, fully supporting medical necessity for the service(s) requested. Since the physician offices typically maintain the patient’s medical record, it is imperative that Part B providers work closely with the OPD to ensure they have all necessary information to obtain the PAR prior to rendering services requiring PA.
Although PA is mandatory only for hospital OPD services, CMS advises providers that claims for related services, such as anesthesiology and physician services, will not be paid if the primary service lacks eligible prior authorization. Only associated services performed in the OPD setting are impacted, and these may be automatically denied or denied post-payment if the required PA is not obtained.
Decisions for PARs:
- Provisional affirmation
- Preliminary finding indicates that the future claim submitted to Medicare for the service(s) requested are likely to meet Medicare’s coverage, coding and payment requirements.
- Non-affirmation
- Preliminary finding indicates that the future related claim for the service(s) requested do not meet Medicare’s coverage, coding and payment requirements.
- Provisional partial affirmation
- Preliminary finding indicates that at least one requested service was affirmed and the future claim for that specific service will likely to meet Medicare’s coverage, coding and payment requirements.
- Preliminary finding indicates that at least one requested service was non-affirmed and the future claim for that specific service will likely not meet Medicare’s coverage, coding and payment requirements.
The hospital OPD, physician and beneficiary will receive a decision letter from the MAC for any clinical decision rendered.
Revised 6/23/2025