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Prior Authorization Exemption for Certain DMEPOS Items


Prior Authorization Exemption for Certain DMEPOS Items

On 4th April 2022, CMS published a rule on “suspension of prior authorization requirements for orthoses prescribed and furnished urgently or under special circumstances”. Prior authorization helps Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers ensure that applicable Medicare coverage, payment, and coding rules are met before DMEPOS items are delivered. The prior authorization program helps to protect the Medicare Trust Fund from improper payments while ensuring that beneficiaries can receive the DMEPOS items they need in a timely manner.

CMS maintains a master list of DMEPOS items that requires either a face-to-face encounter and written order or prior authorization requirements. You will find the updated list here. Due to the need for certain patients to receive an orthoses item that may otherwise be subject to prior authorization when the two-day expedited review would delay care and risk the health or life of the beneficiary, CMS suspended prior authorization requirements for HCPCS codes L0648, L0650, L1832, L1833, and L1851 furnished under following circumstances:

  • Claims for these HCPCS codes that are billed using modifier ST will not undergo prior authorization and will instead be subject to 100% prepayment review.
  • For suppliers furnishing these items under a competitive bidding program exception (as described in 42 CFR 414.404(b)), claims billed with modifiers KV, J5, or J4 would convey that the DMEPOS item is needed immediately and therefore these modifiers will be accepted in addition to the ST modifier. Ten percent of claims submitted using the KV, J5, or J4 modifiers for HCPCS L0648, L0650, L1833, and L1851 will be subject to prepayment review.

Prior authorization will continue for these orthoses items (HCPCS L0648, L0650, L1832, L1833, and L1851) when furnished under circumstances not covered in this update, as well as all other items on the Required Prior Authorization List

Prior Authorization Requirements for DMEPOS

Defining Prior Authorization:

Prior authorization is a process through which a request for provisional affirmation of coverage is submitted for review before a DMEPOS item is furnished to a beneficiary and before a claim is submitted for payment. Prior authorization helps ensure that applicable coverage, payment, and coding rules are met before supplies are delivered.

Prior Authorization Process for Certain DMEPOS Final Rule:

The final rule establishes a prior authorization process for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items through a two-step process. First, the rule establishes a Master List of DMEPOS items that are frequently subject to unnecessary utilization and potentially subject to prior authorization based on certain criteria.

Second, it creates a “Required Prior Authorization List,” a subset of items on the Master List that are subject to prior authorization. CMS will inform the public of those items on the Required Prior Authorization List by publishing a notice in the Federal Register with 60-days’ notice before implementation.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle solutions. Our team is well versed with all the billing and coding updates for various medical specialties including DME.

We can help you to receive accurate insurance reimbursements for DME items including prior authorizations. To know about our DME billing services, contact us at info@ medicalbillersandcoders.com/ 888-357-3226

Reference: FAQs on Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Items Final Rule

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