It is noteworthy to understand that an affirmative PAR decision follows the patient not the provider. Supplier A could have done all the work to obtain the PAR and the patient can choose another provider to supply them with the DMEPOS.
Be careful if a patient has obtained a PAR approval with another supplier. As you may still require all their documentation if you are subject to either a TPE or post payment review.Thus if you find yourself in this position (within the 60 day window), do not submit another PAR as it may l be denied as a duplicate
Instead contact the other supplier and obtain all the information they submitted to Medicare.
If a PAR is continued to be denied, you have several choices.
Refuse to provide the service and find an alternative meeting the patient’s needs
Have the patient sign a very specific ABN. Theclaim would need to be amended with the GA modifier.
For podiatrists, the only AFO currently listed requiring a Prior Authorization Request (PAR) is for L1951 a very specific custom fitted AFO.
The PA program by regulation must either provide you with an affirmative or non affirmative response within 5 business days for a standard PAR or 2 business days for an expedited PAR.
In the case where the patient has an emergent need for a specific device, as in the case of a bad sprain or fracture, the HCPCS code can also be amended with an ST (Stat) modifier. This will allow your claim to by pass the mandatory PAR edit. However, it will more than likely result in the claim being subject to a pre-payment review.This will allow the provider to dispense a product without having to wait for a response from the DME MAC, but not without having the possiblity of having the claim denied if the documentation on review does not support medical necessity.
Your DME MAC within the alloted time will send you an affirmative decision with a Unique Tracking Number which can be affixed to the claim. Your EHR vendor should be able to assist you with this.
For claims deemed as non affirmative for lack of medical necessity you can submit additional documentation via the portal endless number of times.
All PAR decisions are good for 60 days and the patient must be provided with the DMEPOS within 60 days of the affirmative decision.
Your EHR and all supportive chart documentation can be uploaded to the provider portal (NMP for DME MAC A or D or MyCGS for DME MAC B and C) by using the Prior Authorization Button.You can also track the progres through the portal by doing a PAR inquiry.
There are also other PAR requirements for bone stimulators (both electromagnetic and ultrasound) which were to go into effect later this month, but have now been postponed until Mid September.
There are other PA programs either currently or soon to be implemented, however DPMs generally prescribe and do not dispense these services.
The bottom line is whether you dispsense or only prescribe, your supportive documentation will be subject to more scruitny. Any vendor if also the DMEPOS biller will definitely want to secure and review your documentation before they provide your patient with any product subject to a PAR.
I would urge you to review the CMS website listed towards the top of this posting and also search your DME MAC webpage for more information.
Part II on PA program.
It is noteworthy to understand that an affirmative PAR decision follows the patient not the provider. Supplier A could have done all the work to obtain the PAR and the patient can choose another provider to supply them with the DMEPOS.
Be careful if a patient has obtained a PAR approval with another supplier. As you may still require all their documentation if you are subject to either a TPE or post payment review.Thus if you find yourself in this position (within the 60 day window), do not submit another PAR as it may l be denied as a duplicate
Instead contact the other supplier and obtain all the information they submitted to Medicare.
If a PAR is continued to be denied, you have several choices.
Refuse to provide the service and find an alternative meeting the patient’s needs
Have the patient sign a very specific ABN. Theclaim would need to be amended with the GA modifier.
The Medicare DMEPOS prior authorization is based on specific HCPCS codes which are posted on a “DMEPOS Master List”. These can be found on any of the DME MAC websites on the CMS website at Master List of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Items Potentially Subject to Conditions of Payment | CMS
For podiatrists, the only AFO currently listed requiring a Prior Authorization Request (PAR) is for L1951 a very specific custom fitted AFO.
The PA program by regulation must either provide you with an affirmative or non affirmative response within 5 business days for a standard PAR or 2 business days for an expedited PAR.
In the case where the patient has an emergent need for a specific device, as in the case of a bad sprain or fracture, the HCPCS code can also be amended with an ST (Stat) modifier. This will allow your claim to by pass the mandatory PAR edit. However, it will more than likely result in the claim being subject to a pre-payment review.This will allow the provider to dispense a product without having to wait for a response from the DME MAC, but not without having the possiblity of having the claim denied if the documentation on review does not support medical necessity.
Your DME MAC within the alloted time will send you an affirmative decision with a Unique Tracking Number which can be affixed to the claim. Your EHR vendor should be able to assist you with this.
For claims deemed as non affirmative for lack of medical necessity you can submit additional documentation via the portal endless number of times.
All PAR decisions are good for 60 days and the patient must be provided with the DMEPOS within 60 days of the affirmative decision.
Your EHR and all supportive chart documentation can be uploaded to the provider portal (NMP for DME MAC A or D or MyCGS for DME MAC B and C) by using the Prior Authorization Button.You can also track the progres through the portal by doing a PAR inquiry.
There are also other PAR requirements for bone stimulators (both electromagnetic and ultrasound) which were to go into effect later this month, but have now been postponed until Mid September.
There are other PA programs either currently or soon to be implemented, however DPMs generally prescribe and do not dispense these services.
The bottom line is whether you dispsense or only prescribe, your supportive documentation will be subject to more scruitny. Any vendor if also the DMEPOS biller will definitely want to secure and review your documentation before they provide your patient with any product subject to a PAR.
I would urge you to review the CMS website listed towards the top of this posting and also search your DME MAC webpage for more information.
I understand that Medicare now has a prior authorization program for certain DMEPOS. How will that effect me and my patients? - WoodsideDR