Prior Authorization in Medical billing

Medicare prior Authorization

Prior authorization is a process through which a request for provisional affirmation of coverage is submitted to a medical review contractor 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/requester (for example, provider, supplier, beneficiary) to send in medical documentation, in advance of the item or service being rendered, and subsequently billed, in order to verify its eligibility for Medicare claim payment.

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

• Meet all other applicable Medicare coverage, coding and payment requirements Contractors shall, at the direction of CMS or other authorizing entity, conduct prior authorizations and alert the requester/submitter of any potential issues with the information submitted.

A prior authorization request decision can be either a provisional affirmative or a nonaffirmative 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. MACs shall provide notification of the reason for the non-affirmation, if a request is non-affirmative, to the submitter/requester. If a prior authorization request receives a non-affirmative decision, the prior authorization request can be resubmitted an unlimited number of times.

• Prior authorization may also be a condition of payment. This means that claims submitted without an indication that the submitter/requester received a prior authorization decision (that is, Unique Tracking Number (UTN)) will be denied payment.

Prior Authorization Program for DME MACs

A prior authorization program for certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items that are frequently subject to unnecessary utilization is described in 42 CFR 414.234. Among other things, this section establishes a Master List of certain DMEPOS items meeting inclusion criteria and potentially subject to prior authorization. CMS will select Healthcare Common Procedure Coding System (HCPCS) codes from the Prior Authorization Master List to be placed on the Required Prior Authorization List, and such codes will be subject to prior authorization as a condition of payment. In selecting HCPCS codes, CMS may consider factors such as geographic location, item utilization or cost, system capabilities, administrative burden, emerging trends, vulnerabilities identified in official agency reports, or other data analysis.

• The Prior Authorization Master List is the list of DMEPOS items that have been identified using the inclusion criteria described in 42 CFR 414.234.

• The List of Required DMEPOS Prior Authorization Items contains those items selected from the Prior Authorization Master List to be implemented in the Prior Authorization Program. The List of Required DMEPOS Prior Authorization Items will be updated as additional codes are selected for prior authorization.

• CMS may suspend prior authorization requirements generally or for a particular item or items at any time and without undertaking rulemaking. CMS provides  notification of the suspension of the prior authorization requirements via Federal Register notice and posting on the CMS prior authorization website.

What is Prior Authorization

Prior authorization is the process of obtaining approval in advance of a planned inpatient admission or rendering of an outpatient service. Prestige Health Choice will make an authorization decision based on the clinical information provided in the request. Prestige Health Choice may request additional information that may include a medical record review.

Reasons for requiring authorization may include:
• Review for medical necessity
• Appropriateness of rendering provider
• Appropriateness of setting
• Case and disease management considerations

Prior Authorization is required for elective or non-urgent services as designated by Prestige Health Choice. Guidelines for prior authorization requirements by service type and/ or code are available by calling Prestige Health Choice, or by referring to the Benefit Grid found in the Providers area of the Prestige Health Choice Website at: http://www.prestigehealthchoice.

The prior authorization request should include the patient’s diagnosis (ICD-9), and the CPT code describing the anticipated procedure. If the procedure performed and billed is different from that on the request, but within the same family of services, a revised authorization is not required.

• The attending physician or designee is responsible for obtaining the prior authorization for the elective or non-urgent procedure or admission.

• An authorization is the approval necessary to be granted payment for covered services and is provided only after Prestige Health Choice agrees the treatment is necessary and a covered benefit.

• An Authorization Request form must be completed by the provider in order to obtain an authorization from Prestige Health Choice. A copy of this form is included in the Forms section of the manual. This form may be faxed to 800-338-4195

• This form must be filled out completely and legibly in order to be processed quickly.

• A current and operating fax number with area code must be  included in order to receive an authorization number by return fax.

Providers may request a “stat” authorization (for services that are urgent in nature) by:

• Calling Prestige Health Choice (have the member’s name, ID number, diagnosis and service available when calling) at 888-611-0784.


There may be occasions when a beneficiary requires services beyond those ordinarily covered by Medicaid or needs a service that requires prior authorization (PA). In order for Medicaid to reimburse the provider in this situation, MDHHS requires that the provider obtain authorization for these services before the service is rendered. Providers should refer to their provider-specific chapter for PA requirements.

(Refer to the Directory Appendix for contact information for PA.) Requests for PA (except pharmacy) may be submitted in writing, via Direct Data Entry (DDE) through CHAMPS, or electronically (utilizing the ASC X12N 278 5010 Health Care Services Review/Request transaction) if the provider is an MDHHS-approved EDI submitter. Providers wishing to submit a 278 transaction should refer to the Electronic Submission Manual and the MDHHS Companion Guide for the HIPAA 278 Health Care Services Review/Request transaction for further information. Both documents are available on the MDHHS website. (Refer to the Directory Appendix for website information.) Refer to the Pharmacy Chapter for information related to pharmacy PA.

PA requirements for MHP enrollees may differ from those described in this manual. Providers should contact the individual plans regarding their authorization requirements.PA may not be required if the beneficiary has Medicare or other insurance coverage. (Refer to the Coordination of Benefits Chapter for additional information.) 10.1.A. FFS DIRECT DATA ENTRY (DDE) IN CHAMPS The CHAMPS PA system allows FFS providers to submit single PA requests through the nline web portal. CHAMPS validates both beneficiary and provider information. An error message is returned to the user if the information is incorrect. Any provider may request PA, however, the provider NPI entered in the servicing provider field must represent the provider who will be rendering the service. Once the PA request is successfully entered, the provider receives a tracking number. If the request is approved by MDHHS, this tracking number becomes the prior authorization number to use for billing purposes. The tracking number is not valid for claims unless a PA request is approved. Modifications to existing prior authorizations on file can be requested via fax to the Program Review Division. Private Duty Nursing providers with an authorization on file for a beneficiary in the Children's Waiver Program or Habilitation Supports Waiver should contact the Community Mental Health Services Program (CMHSP) for assistance. (Refer to the Directory Appendix for contact information.) Supporting documentation may be linked to a DDE PA request either through facsimile or electronically. For electronically-submitted documentation, the DDE screen will open Internet Explorer on the user's computer and allow the retrieval of the appropriate record to link to the PA request. The system limits each PA request to 10 document attachments; each attachment is limited to a maximum size of 100MB. For documents submitted via facsimile, CHAMPS generates a cover sheet pre-populated with the beneficiary's ID number and the tracking number of the request. The fax cover sheet contains the applicable fax number and must precede the documents being uploaded into CHAMPS. There is no system limit for the maximum number of pages for faxed documents.

PA Inquiry allows providers to check on the status of submitted PA requests or query on completed PAs on file. Up to seven (7) years of PA history is accessible to providers in CHAMPS.

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