New Year – New CMS Ruling for Prior Authorizations for Four States Starts March 20, 2017

CMS announced in the Federal Register on Dec. 21 the selection of two power mobility devices to be subject to required prior authorization beginning March 20, 2017:

  • K0856: Power wheelchair, Group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
  • K0861: Power wheelchair, Group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

Suppliers or beneficiaries submitting claims in one of the four states listed below must receive prior authorization before the item is furnished or a claim is submitted as a condition for payment:

  • Illinois
  • Missouri
  • New York
  • West Virginia

CMS also announced its intent to expand the prior authorization process for codes K0856 and K0861 nationwide in July 2017.

The intent behind this new ruling is the prior authorization process will require the same information necessary to support Medicare payment today, just earlier in the process. It will not create new clinical documentation requirements. The prior authorization process assures that all relevant coverage, coding and clinical documentation requirements are met before the item is furnished to the beneficiary and before the claim is submitted for payment.

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