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The Prior Authorization Process: Need-to-Know Changes for 2021

The Centers for Medicare & Medicaid Services (CMS) is updating the prior authorization process for hospital outpatient departments that began on July 1, 2020. As part of the 2021 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule, CMS is adding Implanted Spinal Neurostimulators and Cervical Fusion with Disc Removal to the prior authorization process for services provided on or after July 1, 2021.

Prior authorization will need to be obtained for the following new groups of services as of July 1:

  1. Implanted Spinal Neurostimulators: Prior authorization will only be required when CPT® code 63650 is reported. CMS has temporarily removed CPT® codes 63685 and 63688 from the list of services requiring prior authorization. CMS will be monitoring prior authorization for spinal neurostimulators to determine if additional codes will be added in the future. It is also important to note that prior authorization will only be required for trial implantation procedures for providers reporting both trial and permanent implantation procedures using 63650.
  2. Cervical Fusion with Disc Removal: Prior authorization will be required for claims containing CPT® code 22551 or 22552.

In addition to the two new services above, the prior authorization process will remain in effect for the five groups of services previously identified to be at high risk for improper payments, including: Blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation procedures. The full listing of impacted codes can be found at https://www.cms.gov/files/document/opd-services-require-prior-authorization.pdf.

As a reminder, a prior authorization request should be submitted to your Medicare Administrative Contractor (MAC) for all Medicare patients who are scheduled to undergo one or more of these procedures if your hospital has not received a Notice of Exemption. Although there is not a single national form for submitting the requests, the following elements should be included when submitting your request to avoid processing delays:

  1. Beneficiary information: Patient name, Medicare beneficiary identifier, and date of birth are required.
  2. Hospital outpatient department information: Facility name, PTAN/CCN, National Provider Identifier (NPI), and address should be included.
  3. Physician information: The performing physician’s name, address, PTAN, and NPI are required.
  4. Requestor information: The requestor should provide their name, phone number, and address. Note that the hospital is responsible for obtaining the authorization, but it is permissible for the physician to assist the facility in obtaining the required information.
  5. Other information: The request should include the anticipated date of service, HCPCS codes, diagnosis codes, type of bill, units of service, indication of whether the request is an initial or subsequent review request, and the reason that an expedited review is being requested (if applicable).

In February 2021, the MACs worked to identify hospitals who qualified for the current exemption cycle and provided these hospitals with a written Notice of Exemption in March. Hospitals who received affirmations at least 90% of the time on their submitted prior authorizations should have received a Notice of Exemption from the prior authorization process for dates of service on or after May 1, 2021. If your hospital received a Notice of Exemption, you do not need to submit prior authorization requests during the exemption cycle. Any prior authorization requests received during the exemption cycle will be rejected by the MAC.

In September 2021, exempt providers can expect to receive an Additional Documentation Request from their MAC which will be used to determine whether the hospital will continue as an exempt facility for the next exemption cycle. Once the Additional Documentation Request is received, you will have 45 days to provide 10 claims containing at least one of the seven services which require prior authorization. If your facility falls below the 90% affirmation threshold, you will receive a Notice of Withdrawal of Exemption no later than December 17, 2021, and you will be required to submit prior authorization requests for services provided on or after March 1, 2022, per the established process. If your facility is found to meet the 90% threshold for continued exemption, you can expect to receive a Notice of Exemption for the next exemption cycle.

Hospitals who did not receive a Notice of Exemption in March will also be assessed in September to determine whether they qualify to receive a Notice of Exemption for the next cycle. This exemption cycle assessment will continue every March and September. Questions regarding your hospital’s affirmation rates or your current exemption status should be directed to your MAC. A current listing of MAC websites is available at https://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/MAC-Website-List.

Organization is key to this process, so it is recommended that a single point person be given responsibility for tracking patients who will require prior authorization and for following up on decision letters, although a team will likely be necessary to obtain and submit the required information and to ensure that back-up is available when the main contact is unavailable. A log should be kept for all submitted requests, decisions received, and final billing outcomes. Remember that this is a new process for everyone, so denials may be issued incorrectly by the MACs. Should you receive a denial, full appeal rights are available and should be utilized when appropriate.