Outpatient Department Prior Authorization (PA)

Published 11/01/2024

The Centers for Medicare & Medicaid Services (CMS) has established a nationwide prior authorization (PA) process and requirements for certain hospital outpatient department (OPD) services. This process serves as a method for controlling unnecessary increases in the volume of these services and to ensure that medical necessity is met. 

  • Blepharoplasty
  • Botulinum toxin injections
  • Panniculectomy
  • Rhinoplasty
  • Vein ablation

Providers can submit a PA request as early as June 17, 2021, for date of service on or after July 1, 2021, for the following:

  • Cervical Fusion with Disc Removal
  • Implanted Spinal Neurostimulators

Providers can submit a PA request as early as June 15, 2023, for date of service on or after July 1, 2023, for the following:

  • Facet Joint Interventions

Please watch our website for upcoming education regarding OPD PA. You may go to the CMS website to view a full list of HCPCS codes that require a PA.

Resources


12/20/2024
Review and Decision Timeframe Update
Effective January 1, 2025, the CMS will reduce the timeframe requirements for Medicare Administrative Contractors (MACs) to provide a hospital outpatient department (OPD) prior authorization request (PAR) provisional affirmed or non-affirmed decision within seven calendar days of receipt of the request.
12/20/2024
12/17/2024
Outpatient Department Prior Authorization Decision and Timeframe Alert!
Effective January 1, 2025, CMS will reduce the timeframe requirements for Medicare Administrative Contractors (MACs) to provide a hospital outpatient department (OPD) prior authorization request (PAR) provisional affirmed or non-affirmed decision within seven (7) calendar days of receipt of the request.
12/17/2024
10/28/2024
Cervical Fusion with Disc Removal Best Practices
Cervical discectomy with disc removal is a surgical procedure that may relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness, and tingling. The procedure is accompanied by a fusion surgery to stabilize the spine. Providers should include the documentation listed in this article with their Cervical Fusion with Disc Removal PA request.
10/28/2024
8/15/2024
Cervical Fusion with Disc Removal Hospital Outpatient Department Required Documentation
This surgical procedure may relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness, and tingling. The procedure is accompanied by a fusion surgery to stabilize the spine. Effective for dates of service July 1, 2021, and after, hospital outpatient department (HOPD) providers will need to obtain prior authorization (PA) for cervical fusion with disc removal if performed in a HOPD setting and billed with the codes listed in this article.
8/15/2024
8/7/2024
Facet Joint Interventions for Pain Management
Facet joint interventions may be used in pain management for chronic cervical/thoracic and lumbar/sacral pain arising from the paravertebral facet joints. Imaging guidance (fluoroscopy or CT per code descriptor) is used to assure accurate placement of the needle for the injection. Paravertebral facet joint denervation is a therapeutic intervention used to provide both long-term pain relief and reduce the likelihood of recurrence of chronic cervical/thoracic or lumbar/sacral pain confirmed as originating in the facet joint’s medial branch nerve. 
8/7/2024
8/6/2024
Cervical Fusion with Disc Removal Checklist
Cervical Fusion is a surgical procedure that may relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness, and tingling. Hospital outpatient department (HOPD) providers will need to obtain prior authorization (PA) for cervical fusion with disc removal if performed in a HOPD setting and billed with the following CPT® codes.
8/6/2024
3/11/2024
Rejected Prior Authorization Requests Module
A prior authorization request (PAR) is rejected when Palmetto GBA is unable to process the request due to incomplete or invalid information. Palmetto GBA will notify the submitter/requestor that their request was rejected and the reason why. The common rejection reasons and the corrective action for each rejection are listed in this module. 
3/11/2024
1/24/2024
Rejected Prior Authorization Request
A prior authorization request (PAR) is rejected when Palmetto GBA is unable to process the request due to incomplete or invalid information. Palmetto GBA will notify the submitter/requestor that their request was rejected and the reason why.
1/24/2024
8/15/2023
Expedited Review of a Prior Authorization Request
The requester can submit an expedited review of the PAR if it is determined that a delay could seriously jeopardize the beneficiary’s life, health or ability to regain maximum function. When requesting an expedited review, the provider must include an explanation why this procedure needs to be performed urgently.
8/15/2023
5/24/2023
Blepharoplasty and Medical Necessity Module
The Blepharoplasty and Medical Necessity Module provides an introduction to blepharoplasty. This module focuses on Medicare coverage guidelines for blepharoplasty; documentation requirements for eyelid surgeries and photographic guidelines to support medical necessity of eyelid surgeries.
5/24/2023
5/10/2023
Facet Joint Interventions Checklist
This article includes a checklist for the facet joint interventions documentation requirements.
5/10/2023
2/26/2023
New Service Added to the Hospital Outpatient Department Prior Authorization Program
Effective for dates of service rendered on or after July 1, 2023, facet joint interventions are being added to the Hospital Outpatient Department (OPD) services requiring prior authorization as a condition of payment. On June 15, 2023, Palmetto GBA will begin accepting prior authorization requests for facet joint services.
2/26/2023
12/14/2022
Outpatient Prior Authorization Status Tool: Job Aid
This job aid notifies providers of the steps taken to conveniently obtain the status of outpatient prior authorization request using the Prior Authorization Status Tool.
12/14/2022
10/6/2022
Blepharoplasty and Medical Necessity Module
The Blepharoplasty and Medical Necessity Module provides an introduction to blepharoplasty. This module focuses on Medicare coverage guidelines for blepharoplasty; documentation requirements for eyelid surgeries and photographic guidelines to support medical necessity of eyelid surgeries.
10/6/2022
5/12/2022
Medicare Exemption: Prior Authorization of Certain Hospital Outpatient Services Video
This video was a collaboration between all the CMS Medicare Administrative Contractors to address frequently asked questions related to the Outpatient Hospital Department Prior Authorization services. The specific topic of the video is the exemption process.
5/12/2022
4/12/2022
Panniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy), and Related Services
Abdominal lipectomy/panniculectomy is surgical removal of hanging excessive fat and skin in a transverse or vertical wedge from the abdomen but does not include muscle plication or flap elevation.
4/12/2022
1/20/2022
Hospital Outpatient Department (OPD) Prior Authorization Exemption Process
Hospital Outpatient Departments (OPDs) who demonstrate compliance with Medicare coverage, coding, and payment rules related to prior authorization (PA) may be eligible for exemption. This exemption would remain in effect for a twelve-month period or until CMS elects to withdraw the exemption.
1/20/2022
12/15/2021
Botulinum Toxin Injections
Medicare allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member. Botulinum toxin injections are not covered for cosmetic purposes. Palmetto GBA Local Coverage Determination L33458 outlines twelve conditions where chemodenervation techniques may be covered/indicated. The coverage indications are specific and include limitations. Details of coverage indications are available in the L33458 local coverage determination in the reference section included with this updated article.
12/15/2021
11/19/2021
Vein Ablation and Related Services Checklist
This article includes information about the Vein Ablation and Related Services Checklist.
11/19/2021
10/12/2021
Implantation of Spinal Neurostimulator
CMS covers the implantation of central nervous system stimulators as a therapy for the relief of chronic intractable pain. ​​​​​​​A dorsal column (or spinal cord) neurostimulator is the surgical implantation of neurostimulator electrodes within the dura mater (endodural) or percutaneous insertion of electrodes in the epidural space.
10/12/2021
9/17/2021
Rhinoplasty
This article includes information about Rhinoplasty documentation.
9/17/2021
8/31/2021
How to Check Your Outpatient Department Prior Authorization (OPD) Results Status
OPD providers can check their cycle results in eServices.
8/31/2021
7/15/2021
Hospital Outpatient Department (OPD) Prior Authorization Exemption Process
Hospital Outpatient Departments (OPD) that demonstrate compliance with Medicare coverage, coding, and payment rules related to prior authorization are eligible for exemption. This exemption would remain in effect for a six-month period or until CMS elects to withdraw the exemption. To be eligible, OPDs need to submit at least 10 prior authorization requests during the previous review period and achieve a provisional affirmation threshold of at least 90 percent during a semiannual assessment. Notice of an exemption or withdrawal of an exemption will be provided at least 60 days prior to the effective date.
7/15/2021
7/2/2021
Vein Ablation and Related Services
This article explains vein ablation and other related services. It also explains which services are covered under Medicare.
7/2/2021
6/30/2021
Outpatient Department Prior Authorization Exemption
The Centers for Medicare
6/30/2021
6/4/2021
Cervical Discectomy Checklist
A Cervical Discectomy is a type of neck surgery that involves removing a damaged disc to relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness, and tingling.
6/4/2021
Spinal Cord Stimulator Checklist
A Spinal Cord Stimulator is an implanted device that sends low levels of electricity directly into the spinal cord to relieve pain. The documentation requirements.
6/4/2021
5/27/2021
Outpatient Prior Authorization (OPA) Status Tool
Use this tool to retrieve the status of your prior authorization request.
5/27/2021
4/29/2021
ADRs for Outpatient Department Prior Authorization services (OPD PA) Services
When responding to an ADR for OPD PA, please use a cover letter or form that identifies the record as an OPD ADR response. This will facilitate the review process.
4/29/2021
4/8/2021
Outpatient Department (OPD) Prior Authorization (PA)
OPD PAs cannot be sent retroactively, they must be submitted prior to the beneficiary receiving the service.
4/8/2021
1/20/2021
esMD for the Review Choice Demonstration (RCD) and the Outpatient Department (OPD) Prior Authorization (PA)
Providers using esMD to submit for the Review Choice Demonstration (RCD) or the Outpatient Department (OPD) Prior Authorization (PA), should use a coversheet with the demographic information included in this article
1/20/2021
10/19/2020
Outpatient Department (OPD) Prior Authorization (PA) Alert!
As of October 9, 2020, physician/NPP Part B providers are required to provide two (2) fax numbers to receive your Outpatient Department (OPD) Prior Authorization (PA) decision.
10/19/2020
7/2/2020
Outpatient Hospital Department (OPD) Prior Authorization (PA) Fax Number
Please note that the correct fax number for Outpatient Hospital Department (OPD) Prior Authorization (PA) is (803) 462-7313.
7/2/2020
6/25/2020
Outpatient Department (OPD) Prior Authorization (PA) Required Documentation
Please submit the required documentation included in this article when submitting an OPD PA request.
6/25/2020
6/22/2020
Outpatient Department Prior Authorization Calculator
Palmetto GBA’s Outpatient Department Prior Authorization Calculator will help you determine the time you have remaining to perform the approved procedure before the authorization expires.
6/22/2020
6/3/2020
Outpatient Department Prior Authorization (OPD) eServices Submission Guide
Outpatient Department Prior Authorization (OPD) eServices Submission Guide is now available.
6/3/2020
5/27/2020
Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services Frequently Asked Questions
The Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services Frequently Asked Questions are now available.
5/27/2020
The Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational Guide
The Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational Guide is now available.
5/27/2020
5/22/2020
Prior Authorization for Certain Hospital Outpatient Department (OPD) Services Terminology
To ensure your success with Outpatient Department Prior Authorization, this article lists some terms you should know.
5/22/2020
5/14/2020
Blepharoplasty and Blepharoptosis Repair
This article includes information about Blepharoplasty and Blepharoptosis repair.
5/14/2020
Outpatient Department (OPD) Prior Authorizations (PA)
Centers for Medicare & Medicaid Services (CMS) has established a nationwide prior authorization (PA) process and requirements for certain hospital outpatient department (OPD) services.
5/14/2020
Panniculectomy
This article includes information about the Panniculectomy Documentation Checklist.
5/14/2020

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