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In a recent Special Open Door Forum CMS provided more details for the pressure reducing support surfaces prior authorization program. Beginning on July 22, providers in four states will have to submit prior authorization requests for five support surface codes. In October, the program will rollout nationally. See details below.

HCPCS: E0193, E0277, E0371, E0372, E0373

Phase 1 Implementation/Effective Date: July 22, 2019

Phase 1 States: California, Indiana, New Jersey and North Carolina

Phase 2 Implementation/Effective Date: October 21, 2019

Prior Authorization Requests should include:

  • The beneficiary’s name, Medicare Beneficiary Identifier (MBI), date of birth, address
  • The supplier’s name, NSC number, NPI number, address, and phone number
  • The requester’s name, telephone number, NPI (if applicable), and address
  • Submission date
  • Healthcare Common Procedure Coding System (HCPCS) code
  • Indicate if the request is an initial or resubmission review
  • Indicate if the request is expedited and the reason why

Requests also need to include a Detailed Written Order (DWO) and documentation from the medical record to support the medical necessity of the item. Requests can be submitted via mail, fax, esMD, or through the MAC's provider portal.

Initial requests will be completed by the MAC within 5 business days. The MAC has also acknowledged the need for expedited requests in the event the standard timeframe could jeopardize the life or health of the Medicare patient. Expedited requests will be completed within 2 business days.

MACs will communicate prior authorization decisions (affirmative or non-affirmative) in a letter, that includes a unique tracking number (UTN). This number must be includes in the claim to receive payment.

If an initial PA request is denied, providers may resubmit as many times as necessary. According to CMS, a large percent of request are affirmed upon initial submission (80%), with second submissions receiving an even higher affirmation rate (96%).

Are you prepared for the new PA program? Let us help!

The van Halem Group has a team of clinical experts that understand Medicare coverage and documentation requirements. Our clincians can provide your team with custom education based on your patient files to ensure your staff is prepared for the new prior authorization program.

Contact us today for more information!