Prior Authorization will be for ***ONLY ***7 states — CA; IL; NY: NC; MI; Fl and TX
The codes for PA are
PMDs & POVs in group 1, 2,3,4 and 5
All POVs K0800-K0805 & K0809 -K0812
- All standard power group 1 & 2 K0813 – K0829
- All group 2 complex K0835 – K0843
- All group 3 complex without power options K0848 –K0855
- All Ped and grp 4 pwcs K0887 – K0891 (NOTE does not mean grp 4s are covered may help with going to a secondary payer source.
- Miscellaneous pwcs K0898
- EXCLUDED are group 3s (K0856-K0864) but these can still go to ADMC in all jurisdictions.
ACCESSORIES will not be part of the PA for these 7 states ONLY the base will looked at.
Prior Authorization is not mandated BUT if you do not you will only be paid at 75% of the allowed amount and you will be put in the prepay review process which will take at least 30 days for review.
If you are a competitive bid provider you will still be paid your usual amount BUT you will have to go through a prepay review process which will take at least 30 days.
The date has not be set but the supplier community will receive a 30 day notice and the start date will be the date of the order so if you already have claims in process they will continue as previous. Orders received within 3 months after demo begins will be allowed to go through the PA process.
Tentative date end of summer?
You will submit the Prior Authorization request to your DME MAC and they will return post mark within 10 (business)days — if the review is not affirmed you will have unlimited resubmits (resubmits will turn around in 20 (business) days) Each jurisdiction will have dedicated fax for PAs.
The PA will require : F2F progress notes — 7 element order — detailed product description and if therapy evaluation done it will need to be sent in with PA.
The PA demonstration reviews will be looking at Medical review documentation required to be sent in.
This will not prevent post pay audits and denials if other standard documentation is inaccurate.
The PA payments will follow the same payment floor but will not stop for any prepayment reviews.
All states outside of the 7 PA Demo states will still be subject to prepay review process.
You can go to PAdemo@cms.hhs.gov to email any questions.
They have a q and a at go.cms.gov\PAdemo
Any other questions please call me at
Peggy Walker, RN