Initiate a Prior Authorization Request for OPD Services for Part A Facility

Table of Contents

• Initiate a Prior Authorization Request
  • Request Details
  • Requestor’s Information
  • Rendering Physician Information
  • Attachments

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Initiate a Prior Authorization Request

1.    Click the Prior Authorization button from the NGSConnex homepage.

2. In the Select a Provider panel, click the Select button next to the applicable provider account.

3. Select the Initiate Prior Authorization button.

4. Answer the question, 'Are you submitting a PAR for certain OPD services in conjuction with a Part A Provider?'

• If user answer, 'No', the system will present the Part B Prior authorization form for RSNAT services.

5. If the user answers, 'Yes', the system will request the PTAN and State of the Part A facility where the services will be performed and then display the Part A Authorization form.

Request Details

• Type of Request – click ‘Initial’ or ‘Resubmission’
• Expedited Request – select ‘Yes’ or ‘No’
• Reason for Expedited Request - this field is required if ‘Yes’ is selected in the Expedited Request field
• Procedure Type – select the drop-down arrow to select one of the following procedure types
  • Blepharoplasty/Eyelid/Brow Lift
  • Botulinum Toxin Injection
  • Cervical Fusion
  • Panniculectomy/Excision Excess Skin/Lipectomy
  • Rhinoplasty
  • Spinal Neurostimulators –Permanent
  • Spinal Neurostimulators – Temporary
  • Vein Ablation
  • Facet Joint Interventions
• Procedure Code – select all procedure code(s) you would like included in your request.
  • Botulinum Toxin Injection - submissions that do not include paired codes (procedure and drug codes) or for administration sites other than 64612 or 64615 are not accepted for Prior Authorization review.
• Type of Bill – enter a valid prior authorization type of bill, which consists of three alpha-numeric characters
• Anticipated From Date of Service – The prior authorization decision is valid 120 days from the date of the decision.
• Anticipated To Date of Service – The prior authorization decision is valid 120 days from the date of the decision.
• UTN – the UTN field is only required to be completed when the ‘Type of Request’ selected is a resubmission. The UTN is provided in the initial decision letter.

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Requestor’s Information

• Requestor’s Name – enter the first and last name of the person requesting the Prior Authorization.
• Requestor’s Phone Number – enter the telephone number of the person we should contact if there are questions regarding the request.
• Requestor’s Email Address – enter the email address of the person we should contact if there are questions regarding the request.
• Requestor’s Fax Number – enter the fax number where you can be contacted.

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Rendering Physician Information

• Rendering Physician's First Name
• Rendering Physician's Last Name
• Rendering Physician's Address:
  • Street Address
  • City
  • State
  • Zip Code

5. Select the Next Button to move forward.

6. Enter all the required 'Facility Details' information in the applicable fields. The other 'Facility Details' (PTAN, Name and Federal Tax ID) information will auto-populate based upon the Part A provider PTAN entered, These fields are not editable.

• If the Part A facility has more than one practice location with the same PTAN/NPI you may enter the appropriate practice location where the services will be rendered in the Street Address, City, State and Zip Code fields.
• The NPI of the Part A Facility where the services will be performed is required. 
• The Part A Facility fax number is required. You must enter the Fax number of the facility where the services will be performed.

7. Select the Next button.

8. Enter all the required ‘Beneficiary Details’ information in the applicable fields.

• Medicare Beneficiary Number – You must enter the Medicare beneficiary’s MBI.
• Medicare Beneficiary First Name – You must enter the first name exactly as it appears on the Medicare card.
• Medicare Beneficiary Last Name – You must enter the last name exactly as it appears on the Medicare card.
• Medicare Beneficiary Date of Birth – MM/DD/YYYY format.
• Beneficiary Address
  • Street Address
  • City
  • State
  • Zip Code

9. Select the Next button to Move Forward.

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Attachments

When a Prior Authorization request is initiated, you must provide all pertinent supporting documentation.

1. In the Attachments section you will upload all supporting documentation you would like to submit with your request. You have the option to drag and drop and attachment or browse your computer for an attachment.
2. We will accept most common file formats. There are no limits on the number of attachments you may include with your response. It is recommended that you limit the size of the attachment to 25 MB or less.

3. Your attachments will display, and you can verify that you have added all of the applicable attachments. If an attachment was added in error, you may delete it prior to submitting your response by select the ‘delete’ icon.
4. Click the Next button to move forward.
5. If you are ready to transmit your response to National Government Services, Inc. select the Submit button.

6. A message will display notifying you that your Prior Authorization request has been submitted successfully. In addition, a confirmation email will be sent to the email address associated with your User Profile.
7. Select the Close button to return to the list and respond to another ADR or select the Back button to review your request.

Posted 10/21/2024