Prior Authorization

3.10 – Prior Authorization (Rev. 876; Issued: 04-12-19; Effective: 05-13-19; Implementation: 05-13-19) The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes. A. Overview Prior authorization is a process through which a request for provisional affirmation of coverage is submitted to CMS or its contractors for review before the item or service is furnished to the beneficiary and before the claim is submitted for processing. It is a process that permits the submitter (e.g., provider, supplier, beneficiary, etc.) to send in medical documentation in advance of providing and billing for an item or service, to verify its eligibility for Medicare claim payment. Contractors shall, at the direction of CMS or other authorizing entity, conduct prior authorizations and alert the submitter of any potential issues with the information, as submitted. For any item or service to be covered by Medicare it must: • Be eligible for a defined Medicare benefit category, • Be medically reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and • Meet all other applicable Medicare coverage, coding and payment requirements. Contractors shall communicate to the submitter (and beneficiary upon request) their prior authorization decision and the assigned unique tracking number (UTN), which indicates that the submitter requested a prior authorization, for corresponding claim submissions. For certain prior authorization programs, the requirement to prior authorize is a condition of payment, as further described in the sections below. Absent any explicit CMS instruction to the contrary, submitters may correct identified issues with their prior authorization request(s) and resubmit their request(s) for prior authorization without restriction. Contractors shall conduct prior authorization reviews within the timeframes defined by CMS in the corresponding prior authorization program operational instruction(s). The prior authorization process is further described in following sections. B. Condition of Payment Contractors shall determine if the requirement to prior authorize a particular item or service is a condition of payment, as specified in the individual operational instruction(s). If prior authorization is a condition of payment, claims submitted without an indication that the submitter made a prior authorization request (i.e., UTN) shall be denied upon receipt. C. Outreach and Education Contractors shall educate stakeholders each time a new prior authorization program is launched for a particular item or service, the requisite information and timeframes for prior authorization submissions, and the vehicle(s) for submitting such information to the contractor for assessment. Contractors shall make sure submitters are aware of the timeframes for contractors to render prior authorization decisions, for each individual prior authorization program. Each prior authorization program will have an associated Operational Guide and will be available on the CMS website. Contractors shall, at a minimum, provide public access to agency-developed prior authorization operational guides, by posting the link(s) on their website. Contractors shall hold group or individualized training sessions, as appropriate, to notify the stakeholders of upcoming prior authorization programs and to make sure there is ongoing understanding of the specific requirements for those applicable prior authorization programs. D. Prior Authorization Submission Contractors shall assess the information/documentation included in the prior authorization submission for completeness. Requisite information for individualized prior authorization programs will be included in the operational guides, and shall be available on the CMS website. Requisite information may include, but is not limited to: • Beneficiary Information (i.e., name, Medicare beneficiary identifier, date of birth) • Physician/Practitioner Information (i.e., name, provider identification number, address) • Supplier Information (i.e., name, national supplier clearinghouse (NSC) number, identification number, address) • Documentation from the medical record to support the medical necessity of the item or service, and • Any other relevant documents as deemed necessary by the contractor to process the prior authorization. E. Prior Authorization Decisions Contractors shall notify the submitter if their prior authorization submission results in a provisional affirmative, or non-affirmative decision. • A provisional affirmative decision is a preliminary finding that a future claim submitted to Medicare for the item or service likely meets Medicare’s coverage, coding, and payment requirements. • A non-affirmative decision is a finding that the submitted information/documentation does not meet Medicare’s coverage, coding, and payment requirements, and if a claim associated with the prior authorization is submitted for payment, it would not be paid. Contractors shall provide notification of the reason(s) for the non-affirmation, if a request is non- affirmative, to the submitter. If a prior authorization request receives a non- affirmative decision, the prior authorization request can be resubmitted an unlimited number of times, unless otherwise specified. Contractors shall send detailed decision letters to submitters. As appropriate for the given prior authorization program, contractors shall send detailed decision letters to other stakeholders (e.g., beneficiaries) using their official address on file. In addition, there may be certain prior authorization programs that require the contractors to notify the appropriate entity by other means, such as telephone. If a claim is submitted for payment without an affirmative prior authorization decision on file, contractors shall use their existing processes to either suspend claims for additional review or to process claims as denials, based on each individualized prior authorization program, as detailed in the operational instruction. F. Expedited Request For certain items or services, delays in receipt of a prior authorization decision could jeopardize the life or health of the beneficiary. Contractors shall, for such items or services, expedite their decisions based on the operational instruction. If the claim processing systems would unavoidably delay the delivery of the UTN in an expedited fashion, contractors shall nonetheless render an affirmative or non-affirmative decision to the submitter within the mandated, expedited timeframe. Contractors shall alert the submitter that the decision is being provided as expediently as possible, so that the item or service may be provided, but that the submitter should hold their claim and not submit it until such time as the UTN is received (in order to avoid a claims payment denial).