The Centers for Medicare and Medicaid Services (CMS) is establishing a nationwide prior authorization (PA) process for certain hospital outpatient department (OPD) services. The Agency believes PA 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.
As of July 1, 2020, the following hospital OPD services require Prior Authorization::
- Blepharoplasty
- Botulinum toxin injections
- Panniculectomy
- Rhinoplasty
- Vein ablation
A detailed list of the codes impacted can be found here.
CMS has developed a webpage dedicated to this program and posts updates as they become available. To see the most current developments, please click here.
Consider these next steps to ensure your office is prepared for the new PA processes:
- Verify practice management software and billing software eligibility requests are updated to recognize these CPT Codes requiring PA.
- Establish a protocol to consistently document data required for PA in the medical record.
- Identify and select the PA method that will be most efficient for your office.
- e.g., Payer portal, electronic transaction, fax, telephone or secure email
- Identify best practice for follow-up to ensure PA is processed and/or denials addressed timely
Before your doctor can provide specific services, prior authorization from Medicare may be necessary. Depending on your plan type, you might need prior approval to see a specialist.
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So, which services and types of plans require prior authorization? Below, we’ll explain what you need to know.
What is Prior Authorization for Medicare?
Prior authorization means your doctor must get approval before providing a service or prescribing a medication. Now, when it comes to Medicare Advantage and Medicare Part D, coverage is often plan-specific. Meaning, you should contact your plan directly to confirm coverage.
Medicare Part A Prior Authorization
Medicare, including Part A, rarely requires prior authorization. If it does, you can obtain the forms to send to Medicare from your hospital or doctor. The list mostly includes durable hospital equipment and prosthetics.
Medicare Part B Prior Authorization
Part B covers the administration of certain drugs when given in an outpatient setting. As part of Medicare, you’ll rarely need to obtain prior authorization.
Although, some meds may require your doctor to submit a Part B Drug Prior Authorization Request Form. Your doctor will provide this form. Once the request gets approval, coverage begins.
Also, CMS has added specific cosmetic procedures to the list of outpatient care. The goal is to prioritize medically necessary procedures.
Medicare Part D Prior Authorization
Often, even top Part D prescription drug plans need prior authorization for coverage on specific drugs. Different policies have varying rules, so you’ll need to contact the carrier directly to confirm coverage.
Most Part D plans have forms you can download online. The online option is a useful way to print the documents and take them to your doctor. Your doctor can help you correctly complete the form.
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Also, recipients may directly contact their Part D plan and ask for a mail-in form. You can find the number for Member Services on your plan’s member ID card.
Medicare Advantage Prior Authorization
To obtain out-of-network, specialist, and emergency care, Medicare Advantage recipients may need prior authorization. Unfortunately, if Medicare doesn’t approve the request, the Advantage plan typically doesn’t cover any costs, leaving the full cost to you.
Reports have shown that as many as four out of five members with Advantage plans require prior authorization for certain services. The services most often requiring prior approval are durable medical equipment, skilled nursing facility stays, and Part B drugs.
But, each Advantage plan is different. If you have an Advantage plan, contact your plan provider to determine if or when prior authorization is necessary. Your plan will have forms you can download online.
Also, Advantage members may appeal to their plan’s denial. Yet, most don’t take advantage of this.
How Do I Get Prior Authorization for Medicare?
Refer to your plan documents, including the drug formulary, to see if your treatment requires approval. This information should be on your plan’s website. The Medicare & You handbook also contains more information.
Your provider is responsible for requesting permissions. Be sure to give them all the information they need for submission, ensuring it’s correct. Double-check your plan’s terms as well.
If your provider believes your treatment is medically necessary, they can contact your plan and request an exception if you get denied. The provider must support the request with a statement. Once approved, your plan pays without prior authorization.
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How Long Does it Take to Get Prior Authorization?
It can take days to get prior authorization. Although, if you’re waiting for a drug, you should call your local pharmacy within a week.
Sometimes, permission is either denied or delayed. If this happens, contact your insurance provider to ask why.
FAQs
Does Medicare require prior authorization for MRI?
If the purpose of the MRI is to treat a medical issue, and all providers involved accept Medicare assignment, Part B would cover the inpatient procedure. An Advantage beneficiary might need prior authorization to visit a specialist such as a radiologist.
Does Medicare require prior authorization for a CT scan?
If your CT scan is medically necessary and the provider(s) accept(s) Medicare assignment, Part B will cover it. Again, you might need prior authorization to see an out-of-network doctor if you have an Advantage plan.
How do I get Medicare prior authorizations for a therapy regimen?
You’ll get prior authorization the same way, no matter the service. Your doctor will document medical necessity and send forms to either Medicare or your plan for approval.
Getting Help Understanding Prior Authorization
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Jagger Esch is the Medicare expert for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and MedicareFAQ.com. Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.