Starting October 15, the Centers for Medicare & Medicaid Services (CMS) will require probationary prior authorization for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items billed by newly enrolled suppliers and suppliers undergoing certain changes of ownership. The program is authorized under Section 1866(j)(3) of the Social Security Act and 42 CFR §424.527, which establishes a one-year probationary period for newly enrolled and ownership-changing DMEPOS suppliers.
O&P items include:
- AFO/KAFO codes L-1902, L-1906, L-1971, L-2035, L-2132, L-2134, L-2136, L-4360, L-4361, L-4396, and L-4397
- Knee orthosis codes L-1810, L-1812, L-1820, and L-1821
- Lower-limb orthosis codes L-1652, L-1653, L-1686, and L-1690
- Spinal orthosis codes L-0626, L-0627, L-0628, L-0630, L-0633, L-0635, L-0641, L-0642, L-0643, L-0649, and L-0720
- Upper-limb orthosis codes L-3660, L-3670, L-3760, L-3762, L-3809, L-3908, L-3915, and L3960
The probationary period begins when a supplier submits their first bill for one of the DMEPOS items on the Probationary Prior Authorization List. CMS said it may update the list if new vulnerabilities arise.
The probationary prior authorization process does not replace the existing prior authorization process for certain DMEPOS items. Suppliers participating in the probationary prior authorization process must continue to comply with the existing prior authorization requirements for applicable DMEPOS items.
To see the Probationary Prior Authorization List, visit the CMS website.
