June 9, 2020

Prior Authorization – It’s Not Just for Commerical Payers Anymore

Matt Perron

On July 1, a CMS rule requiring prior authorization for certain hospital outpatient procedures goes into effect. The rational for why CMS is instituting this change is summarized below.  

CMS believes prior authorization 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, at the same time, keeping the medical necessity documentation requirements unchanged for providers. 


Although July 1 is not far away, do not despair! We have a summary of the rule to help prepare you in time. 

First, some of the basics of the rule.  The following procedures now require Prior Authorization when being submitted to Medicare: 

  • Blepharoplasty 
  • Botulinum toxin injections (with a focus on facial injections) 
  • Panniculectomy 
  • Rhinoplasty 
  • Vein ablation 

A discrete list of codes can be found here. 


Since these are mostly designated as cosmetic procedures, it is important to note that it does not change the medical necessity requirements for any of these. After submission for prior auth, they have 10 days to respond but can issue a response in 2 days if the request is urgent. Claims will be required to have the Unique Tracking Number (UTN) or they will be denied. 

Next, a few other things to help you prepare: 

  • Identifying the Procedures – We first need to identify these procedures so they can be routed to staff to be submitted for prior auth. Most of you are already using workqueues of some sort to catch other procedures that require prior auth so this will likely follow a similar process. Also, these often tend to be performed in specific departments on the outpatient side which may also help to identify them. One thing to note is that often clients will auto-approve Medicare Authorizations as they generally don’t require auth so it is critical that you check your system logic and make sure they these authorizations are being marked for review.  
  • The Submission Process There are several ways these requests can be submitted. The request can be mailed, faxed, submitted through the Electronic Submission of Medical Documentation (esMD) or submitted through the Medicare Administrative Contractor (MAC) portal. The submission must contain the following information. 
  1. The beneficiary’s name, Medicare Beneficiary Identifier (MBI), and date of birth 
  2. Name of Facility, PTAN/CCN, address, and NPI 
  3. Physician/Practitioner’s name, NPI, PTAN, and address 
  4. The requester’s name, telephone number, and address 
  5. Anticipated date of service 
  6. HCPCS code, Diagnosis code, type of bill, and units of service 
  7. Indicate if the request is an initial or resubmission review 
  8. Indicate if the request is expedited and the reason why.  
  9. Documentation to support medical necessity (often times including applicable photos) 

You should work with your IT team now to start developing a template with this information so it can be quickly and easily pulled from your EMR. 

  • Review DecisionsAn affirmative decision is valid for 120 days after the date of decision. If a request is partially affirmed or not affirmed, a letter returned to the provider will provide a detailed explanation of the decision. For non-affirmed decisions, there are two courses of action:  
    1. A requester can resolve the non-affirmation reasons and resubmit the request. Unlimited resubmissions are allowed but are not appealable.
    2. A requester can forgo the resubmission process, receive a denial, and appeal said denial.  
  • Physician EducationThe documentation for these submissions will originate from the physician’s office so it is important they understand these requirements and can partner with your auth submission team to ensure the right information is documented. The physician claim can also be denied as part of the “related claim” which is all the more reason to integrate them into this process.  
  • System Configuration Suggestions Here are a few additional things to consider: 
    1. Claim Edits – You should stop these claims if they are missing the UTN and also consider who is the right team to own these edits. 
    2. Community Connect – Make sure your community connect partners are included in the setup as authorizations often cross between them. 

Got it? Good!  

There is still plenty more to this rule but this should give you the information you need to get ready in the next few weeks. Below is a list of really helpful links that CMS provided to answer any other questions you may have. 


Helpful Links: 

If you still have questions or need some guidance to get you ready for July 1, we would love to help! Please contact  Matt Perron  at The Wilshire Group – m.perron@thewilshiregroup.net.   


Matt Perron

Manager, Patient Access

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