By Kay Koch, OTR/L, ATP Rehab Clinical and Education Consultant
Beginning July 17, 2017, K0856, single power option and K0861 multiple power options, Group 3 Power Mobility Devices will be subject to Prior Authorization Review (PAR) nationwide. Prior to this date, the PAR program has been in place since September 1, 2012 and included all POV and standard PMDs, all Group 2 PMDs and all Group 3 non-power PMDs for certain states.
What does PAR provide?
PAR allows the supplier to provide medical record documentation prior to delivery and billing to verify eligibility for a Medicare claim payment.
The PAR request was not, and is not, considered a claim.
Prior Authorization is a condition for payment.
Any claim eligible for this program after July 17, 2017 must go through the prior authorization process prior to delivery or it will be denied.
The 25% penalty reduction does not apply to this program.
How to prepare for PAR
The PAR cover sheet is optional but encouraged.
Submitters are encouraged to include the following information when submitting PAR requests to avoid potential processing delays:
- Beneficiary information:
- Beneficiary Name
- HIC #
- Beneficiary Date of Birth
- Beneficiary address
- Place of Service, and
- Diagnosis code
- Supplier information:
- Supplier name
- Supplier address
- Supplier phone number
- HCPCS code
- Submission date
Supplier must also indicate if this is an initial or subsequent request AND indicate if this is an expedited request, and if so, the reason it is expedited.
It is also important to indicate if the request contains an UPGRADE.
All documentation to support prior authorization must meet all applicable rules, policy, and LCD requirements.
- Face to face
- LCMP/ Specialty Evaluation
- Financial Attestation
- 7 Element Order
- Supplier ATP evaluation
- Detailed Product Description
- Home Assessment/Visit (if available, but not required. The Medicare reviewer may prefer to have the home assessment included in the review)
Documentation must meet the coverage criteria for the wheelchair base and certain accessories/power options that include tilt, recline, and tilt and recline and specialty seat/back cushions.
PAR review for applicable HCPCS codes does not apply to accessories, except those accessories noted above where coverage criteria must be met.
For the 1st PAR request DME MACs will conduct a medical review of the documentation and send a decision letter to the supplier and the beneficiary (if requested) within 10 days (postmark notification) of receiving the request.
Resubmissions are allowable to correct errors or omissions identified in the 1st review. DME MACs will review the medical documentation and send a decision letter to the supplier and beneficiary (if requested) within 20 days of receipt (postmark notification) of the request. Providers have unlimited options to submit subsequent PAR requests.
An expedited request is considered when the usual review time-frames could jeopardize the beneficiary’s life or health. When applicable, DME MACs will render an affirmative or non-affirmative decision and provide the decision to the supplier or beneficiary (if requested) via phone, fax, or other “real-time” communication within 48 hours.
Unsupported expedited requests are downgraded to a standard request.
Keep in mind
This is a preliminary finding that the future claim submitted to the DME MAC will likely meet Medicare’s coverage, coding, and payment requirements. Even if the supplier has an affirmative PAR decision, the claim may still deny due to technical requirements or due to information later provided that was not available at the time of the PAR review. It is highly encouraged to submit all paperwork in sequential order to avoid potential delays in processing.
Following the favorable PAR decision, the DMEPOS item is delivered to the beneficiary and the claim should be submitted with the Unique Tracking Number (UTN) that is provided on the PAR decision letter.
Noridian has a webinar scheduled July 19, 2017 at 10:00 CST/11:00 am EST. Follow this link to register: https://med.noridianmedicare.com/web/jddme/article-detail/-/view/2230715/prior-authorization-condition-of-payment-for-hcpcs-codes-k0856-and-k0861-expanding-nationwide-july-17-2017
Coversheets can be found on the CGS (https://www.cgsmedicare.com/jc/forms/pdf/prior_authorization_coversheet.pdf) and Noridian (https://med.noridianmedicare.com/documents/2230703/6363658/DME+PAR+Coversheet/f32e99bc-7df8-4b7a-b378-2e1776a683fd) DME MAC websites.