NOTE: All in-article links open in a new tab.

Provisional Affirmation as Part of the Prior Authorization for Certain Outpatient Department (OPD) Services

Published on 

Tuesday, June 23, 2020

 | RAC Information 
 | FAQ 

Q:

Can you help me understand what a provisional affirmation prior authorization (PA) decision is as it pertains to the Outpatient Prior Authorization Program set to begin on July 1, 2020? 

 

A:

Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M posted the following information about the Outpatient Department Prior Authorization in their June 22, 2020 Daily Newsletter:

“A provisional affirmation prior authorization (PA) decision is a preliminary finding that a future claim submitted to Medicare for the service(s) likely meets Medicare’s coverage, coding and payment requirements. The provisional affirmation PA decision is valid for 120 days from the date decision was rendered.

Palmetto GBA's Outpatient Department Prior Authorization Calculator will help you determine the time you have remaining to perform the approved procedure before the authorization expires. Just enter the date of the Prior Authorization Affirmation and click Calculate. The tool will tell you the last date your authorization will be valid.”

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.