Prior Authorization

OPD Facility/Physician Communication

What does this mean for the Part B Provider who will be performing the service in the hospital OPD?

The performing provider, must work alongside the hospital OPD staff to obtain PA for the services to be performed in the OPD.

The PAR will require documentation from the patient’s medical record and 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 PA.

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 PA 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 PA, 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(s) likely meet Medicare’s coverage, coding and payment requirements.
  • Non-affirmation
    • 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 or was rejected due to PA for that service is not required.

The hospital OPD and beneficiary will receive a decision letter from the MAC for any clinical decision rendered physicians or other practitioners who provide related services in the hospital OPD for the procedure requiring PA may obtain a copy of the decision letter from the OPD.

Physician claims do not require a UTN. The hospital OPD claim does require a UTN, which is provided in each clinical decision letter.

Revised 5/3/2024