About Hospital OPD PA Model
Table of Contents
About the Hospital OPD PA Model
CMS implemented a PA program for certain hospital OPD services for DOS on or after 7/1/2020. 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 and keeping the documentation requirements unchanged for providers. As a condition of payment, a PAR is required for the following hospital OPD services:
| DOS on or after 7/1/2020 | DOS on or after 7/1/2021 | DOS on or after 7/1/2023 |
|---|---|---|
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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, PA is not required.
General Information
| Question | Description |
|---|---|
| WHO | Hospital OPDs rendering certain OPD services for Medicare beneficiaries that bill Medicare Part A can request PA. While it in the hospital OPD's responsibility to obtain PA, physician's offices may obtain PA on the OPD's behalf. |
| WHAT | The hospital OPD (or requester) will be responsible for submitting a PAR and all required documentation for eight potentially cosmetic and/or high-volume services and their related services. PA must be obtained prior to the services being rendered to Medicare beneficiaries and before the provider can submit claims for payment. 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 applies to hospital OPD services rendered on or after 7/1/2020, 7/1/2021 and 7/1/2023. Please reference the start dates above for each PA program. |
| WHERE | The program applies to both Jurisdiction 6 and Jurisdiction K. |
| 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 with all documentation requirements specific for the procedure type requested. A UTN will be assigned to each PAR that receives a clinical decision: 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 business days from the date of receipt. The Provisional Affirmation UTN will have a validation period of 120 days, with the decision date counting as the first day of the 120-day validation period. |
Related Content
- OPD Operational Guide
- Guidelines for Submitting PA for Certain Hospital Outpatient Department Services
- OPD Frequently Asked Questions
- OPD Open Door Forum Slides 05-28-2020
- Prior Authorization for Certain Hospital Outpatient Department (OPD) Services | CMS
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Revised 5/3/2024