Suppliers delivering a Condition of Payment (COP) covered wheelchair base (HCPCS K0813-K0816, K0820-K0856, or K0861) on or after September 1, 2018, must request prior authorization before delivery. Authorization is a condition of payment, and all applicable claims without prior approval will deny.
Suppliers can submit prior authorization requests via mail, fax, or the DME MAC portals. Additionally, suppliers that pay for and utilize an esMD gateway through a certified HIH can upload requests through those channels.
CMS requires suppliers to secure an authorization even when Medicare is secondary to other insurance coverage.
Submission Requirements
CMS expects suppliers to include the following elements with their authorization request:
If an upgrade is involved, the FTF documentation and 7-element order must include the PMD base that is medically necessary for the beneficiary. Upgraded product information should appear on the Detailed Product Description with a note indicating when a supplier will deliver an upgraded item.
Accessories
The MACs will review same and similar history in the course of their review. They will not, however, review medical necessity for every accessory. Specific options and accessories that address patient limitations can be considered as part of the prior authorization request when evaluations support the need. The MACs often review integral accessories such as:
The MACs exempt from review non-integral accessories such as:
While the Advanced Determination of Medicare Coverage (ADMC) process historically issued individual approvals for accessories, suppliers cannot use ADMC to secure approval of accessories attached to COP eligible bases.
[Get answers to your questions, and keep your team’s billing expertise sharp. Join us on August 16, 2018, at 1:00 PM (ET) for (K)notes.]
Decisions
After completing its prior authorization review, the applicable MAC will provide a provisional decision to the supplier. Upon request, MACs will send a copy of the decision to the beneficiary, but not to the physician.
MACs will respond within 10 business days of an initial submission or within 20 business days for repeat submissions. In special circumstances where the beneficiary’s life or health is in serious jeopardy, suppliers can request an expedited response and receive an authorization decision within two business days.
The authorization decision is not a claim determination. As such, prior authorization decisions cannot be appealed; appeal rights only apply to submitted claims. There is no limit on the number of authorization submissions. If the authorization process is bypassed, the MACs may choose to suspend and develop claims, but they have the discretion to outright deny these claims.
Claims Submission
For all decisions, the MACs issue a letter containing a Unique Transaction Number (UTN) that must be recorded in Box 23 on the 1500 claim form. Electronic claims transmit the UTN in loop 2400 REF02 where REF01 = G1. Always attach the UTN to the base line item and not to accessories.
If the applicable MAC renders a non-affirmative decision, the supplier may:
Claims filed with a non-affirmed UTN will deny, but the denials can be appealed.
Suppliers will have up to six months to deliver the PMD after the MACs issue the UTN.
Effective Date
DME MACs will accept PA review requests for the COP program on August 18, 2018. To remain eligible, suppliers must plan to schedule delivery of the PMDs on or after September 1, 2018. DME MACs will honor all PMD Demonstration and Advanced Determination of Medicare Coverage (ADMC) decisions rendered prior to September 1, 2018.
For more information, the DME MAC websites contain a wealth of PMD resources, and CMS posted an updated FAQ on June 1, 2018, related to the COP prior authorization program.
If you have any questions, give us a shout.
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Source Links
https://www.gpo.gov/fdsys/pkg/FR-2018-06-05/pdf/2018-11953.pdf
https://med.noridianmedicare.com/web/jadme/article-detail/-/view/6547796/transition-of-eligible-pmd-hcpcs-codes-in-the-pmd-demonstration-to-the-required-prior-authorization
Suppliers can submit prior authorization requests via mail, fax, or the DME MAC portals. Additionally, suppliers that pay for and utilize an esMD gateway through a certified HIH can upload requests through those channels.
CMS requires suppliers to secure an authorization even when Medicare is secondary to other insurance coverage.
Submission Requirements
CMS expects suppliers to include the following elements with their authorization request:
- MAC-approved Condition of Payment PA Coversheet
- 7-Element Order
- Face-to-Face (FTF) assessment
- Detailed Product Description (DPD)
- Specialty PT/OT Evaluation (if required)
- Any other relevant medical documentation
If an upgrade is involved, the FTF documentation and 7-element order must include the PMD base that is medically necessary for the beneficiary. Upgraded product information should appear on the Detailed Product Description with a note indicating when a supplier will deliver an upgraded item.
Accessories
The MACs will review same and similar history in the course of their review. They will not, however, review medical necessity for every accessory. Specific options and accessories that address patient limitations can be considered as part of the prior authorization request when evaluations support the need. The MACs often review integral accessories such as:
- Power seating combination tilt and recline (E1007).
- Head control interface (E2327, E2328, E2329, E2330).
- Sip-n-puff interface (E2325).
- Joystick, other than a standard proportional joystick (E2312, E2321, E2373).
- Multi-switch hand control interface (E2322).
- Seat cushions.
The MACs exempt from review non-integral accessories such as:
- Headrests (E0955).
- Lateral hip/trunk supports (E0956).
- Swing away hardware (E1028).
- Electronics (E2310, E2311).
- Leg rests (K0195, K0108, E1012).
- Batteries.
While the Advanced Determination of Medicare Coverage (ADMC) process historically issued individual approvals for accessories, suppliers cannot use ADMC to secure approval of accessories attached to COP eligible bases.
[Get answers to your questions, and keep your team’s billing expertise sharp. Join us on August 16, 2018, at 1:00 PM (ET) for (K)notes.]
Decisions
After completing its prior authorization review, the applicable MAC will provide a provisional decision to the supplier. Upon request, MACs will send a copy of the decision to the beneficiary, but not to the physician.
MACs will respond within 10 business days of an initial submission or within 20 business days for repeat submissions. In special circumstances where the beneficiary’s life or health is in serious jeopardy, suppliers can request an expedited response and receive an authorization decision within two business days.
The authorization decision is not a claim determination. As such, prior authorization decisions cannot be appealed; appeal rights only apply to submitted claims. There is no limit on the number of authorization submissions. If the authorization process is bypassed, the MACs may choose to suspend and develop claims, but they have the discretion to outright deny these claims.
Claims Submission
For all decisions, the MACs issue a letter containing a Unique Transaction Number (UTN) that must be recorded in Box 23 on the 1500 claim form. Electronic claims transmit the UTN in loop 2400 REF02 where REF01 = G1. Always attach the UTN to the base line item and not to accessories.
If the applicable MAC renders a non-affirmative decision, the supplier may:
- Resubmit the authorization request, or
- Issue an ABN based on the medical necessity failures and file the claim with the non-affirmed UTN.
Claims filed with a non-affirmed UTN will deny, but the denials can be appealed.
Suppliers will have up to six months to deliver the PMD after the MACs issue the UTN.
Effective Date
DME MACs will accept PA review requests for the COP program on August 18, 2018. To remain eligible, suppliers must plan to schedule delivery of the PMDs on or after September 1, 2018. DME MACs will honor all PMD Demonstration and Advanced Determination of Medicare Coverage (ADMC) decisions rendered prior to September 1, 2018.
For more information, the DME MAC websites contain a wealth of PMD resources, and CMS posted an updated FAQ on June 1, 2018, related to the COP prior authorization program.
If you have any questions, give us a shout.
##
Source Links
https://www.gpo.gov/fdsys/pkg/FR-2018-06-05/pdf/2018-11953.pdf
https://med.noridianmedicare.com/web/jadme/article-detail/-/view/6547796/transition-of-eligible-pmd-hcpcs-codes-in-the-pmd-demonstration-to-the-required-prior-authorization
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