Prior Authorization for Certain Hospital Outpatient Department (OPD) Services-July 1st Launch

CMS believes prior authorization for certain hospital out-patient services will ensure that Medicare beneficiaries continue to receive medically necessary care – while protecting the Medicare Trust Fund from improper payments and, at the same time, keeping the medical necessity documentation requirements unchanged for providers.

The following hospital OPD services will require prior authorization when provided on or after July 1, 2020:

  1. Blepharoplasty
  2. Botulinum toxin injections
  3. Panniculectomy
  4. Rhinoplasty
  5. Vein ablation

The full list of HCPCS codes requiring prior authorization is available here:  https://www.cms.gov/files/document/cpi-opps-pa-list-services.pdf

Additional information from CMS: https://www.cms.gov/research-statistics-data-systems/medicare-fee-service-compliance-programs/prior-authorization-and-pre-claim-review-initiatives/prior-authorization-certain-hospital-outpatient-department-opd-services

Main Line Health Pre-Encounter Department is available for questions at 484-337-1970 option 3.

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