Prior Authorization: Part B Physician Implications

For dates of service on and after 7/1/2020, CMS has implemented a prior authorization program for certain hospital OPD services. This has been done to ensure that Medicare beneficiaries receive medically necessary care while protecting the Medicare Trust Fund from improper payments. Medical necessity documentation requirements for these services remain unchanged and all relative LCDs and NCDs remain in effect.

As of 7/1/2020, the following services require a PAR to be submitted to the MAC:

• • 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

A physician planning to perform any of these services in the hospital OPD may proceed based on the individual hospital’s protocol. Some hospitals may initiate the PAR in collaboration with the physician. Other hospitals may request that the physician initiates the PAR on the hospital’s behalf. In all circumstances, the PAR must include the hospital’s PTAN and NPI. The preferred means of submitting a PAR to National Government Services is via the Part A NGSConnex portal.

PARs may also be submitted by FAX at:

• JK Providers: 317-841-4530

• J6 Providers: 317-841-4528

Once the authorization is affirmed, NGS will respond to the requestor with a decision letter and a UTN. The decision letter will be released via the same means as it was submitted. If the submission of the PAR was via NGS Part A NGSConnex, the decision letter will display in NGSConnex. If the request was faxed, the decision letter will be faxed back to the requestor.

If a PAR is non-affirmed, the decision letter will contain a rationale for the decision and will include instructions to resubmit the PAR.

Part A OPD claims (TOB 13X) for any of the services listed above must include an affirmed UTN on the claims for processing and payment.

A UTN is not required for a Part B claim submitted by a physician, but the PAR must have already been affirmed and a valid UTN issued. The performing physician must be aware that if the Part A claim has a non-affirmative or missing UTN, both the Part A claim and the Part B claim for the associated OPD procedure will not be paid .

Additional information for Part A providers is available on the Medical Review Focus Area on our website.

Posted 10/9/2020