What Part B Providers Need to Know About the Prior Authorization Program for Certain Medicare Services Performed in the Hospital Outpatient Department

Hospitals submitting claims for certain outpatient department services will be required to obtain prior authorization from National Government Services.

As a condition of payment, prior authorization will be required for the following when done in the hospital outpatient setting:

• • 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

Since medical necessity is typically documented in the physician’s medical record, Part B providers will need to work with the hospital outpatient departments to ensure prior authorization is obtained before surgeries. It will then be the responsibility of the hospital OPD to submit the PAR. The requestor is the person or entity that submits the PAR along with the documentation.

CMS provides a list of the specific HCPCS codes that are included in the hospital OPD Prior Authorization Program; therefore, when scheduling these services, please coordinate with the facility.

Claims submitted without the required prior authorization will be denied.

Posted 6/22/2020