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Medicare Initiates Prior Authorization for Certain HOPD Services

Effective 7/1/20 , CMS has established a nationwide prior authorization (PA) process and requirements for the following hospital outpatient department (HOPD) services:

  • Blepharoplasty
  • Botulinum toxin injections
  • Panniculectomy
  • Rhinoplasty
  • Vein ablation

You’ll find the entire listing of CPT codes that require prior authorization here.
CMS says “The provider must submit the prior authorization request” then goes on saying “physicians may complete the request on behalf of the provider (the Hospital OPD).” So technically, this process is the responsibility of the HOPD but “the provider (surgeon) can submit the prior authorization request on behalf of the HOPD.” We recommend the surgeon should take ownership of the PA process. CMS has a 10-day turnaround time for PA requests.
The HOPD will receive written approval from Medicare which will contain a Unique Tracking Number (UTN). That UTN must be on the submitted HOPD UB-04 claim to ensure payment. The decision letter will be sent to the HOPD and the UTN provided is reported only on the UB-04 claim form not the CMS-1500 claim form.
Note: This new prior authorization program does not apply to the above services when performed in an Ambulatory Surgery Center (POS 24) or physician office (POS 11).
CMS has also released an operational guide which you will find helpful.
Check your Medicare Administrative Carrier (MAC) for details including the actual request form. As an example, here is the link to Novitas Jurisdiction JH which includes a link to the prior authorization request hospital outpatient procedures Medicare Part A fax/mail cover sheet.
Lastly, this CMS site has good information in addition to what you’ll find on your MAC’s website.
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