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Prior Authorization for Certain Hospital Outpatient Department (OPD) Services MAC Education and CMS Open Door Forum - Thursday May 28, 2020

Published on 

Wednesday, May 27, 2020

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For the past two weeks the Wednesday@One has included an article about the CMS Prior Authorization Program for Certain Outpatient Department (OPD) Services Program set to begin July 1, 2020.

The May 19th article included MAC specific details about when they would be holding education sessions for Providers. This week’s article is meant to inform you about a CMS Open Door Forum related to the prior authorization program, provide highlights from Palmetto GBA’s education sessions in the form of Q&A’s and discuss the change CMS has made in the timeline for Provider Education from the MACs.

 

CMS Prior Authorization Process and Requirements for Certain Outpatient Hospital Department Services Special Open Door Forum (ODF)

The CMS will be hosting a Special ODF tomorrow Thursday May 28 from 1:30 to 3pm ET.

The ODF announcement can be found in the Thursday May 21, 2020 MLNConnects newsletter.

In the announcement CMS invites hospitals, physicians, practitioners, and other Medicare stakeholders to discuss the prior authorization of certain outpatient hospital department services from the following categories:

  • Blepharoplasty,
  • Botulinum toxin injections,
  • Panniculectomy,
  • Rhinoplasty, and
  • Vein ablation.

Participation Instructions:

  • Participant Dial-in-Number: 888-455-1397
  • Conference ID#: 9375124

I advise those interested in participating to call in five to ten minutes prior to the start time to ensure you hear the entire session.

 

Palmetto GBA Outpatient Prior Authorization (PA) May 26, 2020 Education Sessions

Question: When can I start submitting PA’s?
Answer: You can begin to submit PA’s on June 17, 2020 for services on or after July 1, 2020.

Question: How should a PA be submitted to Palmetto (i.e., fax)?
Answer: On June 17 you will be able to submit a PA via fax or mail. You will be able to submit a PA via eServices on or after July 6, 2020.

Question: What happens if a Prior Authorization Request (PAR) does not contain all of the required information?
Answer: You will receive an “error message.”

Question: Will there be a paper form available for Providers to use?
Answer: At this time there is not a paper form available. A form will be made available in the near future. The form will contain the fax number that it should be sent. However, Palmetto GBA recommends that Providers use eServices once this option is available.

Question: Once I submit a PAR, how will I receive the Decision Letter back from Palmetto GBA?
Answer: The Decision Letter will be processed within 10 days and be sent in the same way that the PA was received. (i.e., if you send the PA by fax you will receive a Decision Letter via fax.)

Question: Once you receive a Provisional Affirmation, how long is it valid?
Answer: It is valid for 120 calendar days from the date the decision was made.

Question: Does this Program apply to the Ambulatory Surgery Center (ASC) setting?
Answer: This question was asked in the first session of the day and then clarified in the section session that no, this program is not applicable to the ASC setting.

In addition to the May 26 Education Sessions, Palmetto GBA has added an Outpatient Department PA webpage to their website where you will find articles related to this program. Also, at the end of the May 26 afternoon session the presenter indicated that Palmetto GBA plans to hold monthly teleconferences once this program has started to be available to answer questions from Providers.

 

CMS Extends MAC Provider Education Deadline

On April 24, 2020 CMS released Transmittal 10061 entitled One-Time Notification: Provider Education for Required Prior Authorization (PA) of Hospital Outpatient Department (OPD) Services. The purpose of this Change Request (CR 11671) is to provide instructions to the MACs regarding provider education on the PA process.

On May 21, 2020 this Transmittal was rescinded and replaced with Transmittal 10155 . The transmittal was updated to change the effective and implementation date from May 26, 2020 to June 17, 2020. All other information remained the same.

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.