AOPA Participates in CMS Forum

The American Orthotic and Prosthetic Association (AOPA) participated in a Medicare Open Door Forum call on March 11 that provided sub-regulatory guidance on the upcoming implementation of Medicare prior authorization for six lower-limb prosthesis Healthcare Common Procedure Coding System (HCPCS) codes. The call was hosted by the Centers for Medicare & Medicaid Services (CMS), and the medical directors from the four Durable Medical Equipment Medicare Administrative Contractors (DME MACs) participated.

AOPA said it received the following new information during the call:

·        DME MACs will issue decisions on initial prior authorization requests within ten business days of receipt of the request.

·        DME MACs will issue decisions on prior authorization resubmissions within ten business days of receipt of the request (previous Medicare prior authorization programs allowed 20 business days for prior authorization resubmissions).

·        DME MACs will issue decisions on expedited prior authorization requests within two business days of receipt. In order to be approved, an expedited request must show that the beneficiary’s life or health is in immediate danger.

·        Prior authorization requests may be submitted through multiple channels including electronic submission, submission through the DME MAC claim portal, by fax, and by mail.

·        For the four states (Pennsylvania, Michigan, Texas, and California) scheduled for implementation of prior authorization for dates of service on or after May 11, the DME MACs will begin accepting prior authorization requests on April 27. For national implementation for dates of service on or after October 8, the DME MACs will begin accepting prior authorization requests on September 24.

·        HCPCS codes that receive provisional affirmation will not be subject to additional medical review except for random error rate and fraud and abuse reviews. This only applies to the six HCPCS codes subject to Medicare prior authorization.

·        DME MACs will provide education when prior authorization requests are denied, allowing providers to correct errors and facilitate resubmission.

·        CMS and DME MACs will closely monitor efforts to adhere to established timeframes for initial decisions and resubmissions.

·        Prior authorization requests will be subject to existing Medicare policy governing coverage of lower-limb prostheses. No changes are being made to the local coverage determination or Policy Article as a result of prior authorization.

AOPA said that while some uncertainty remains, it is confident that Medicare prior authorization can be beneficial to Medicare beneficiaries, providers, and the Medicare program.