Tag Archives: prior authorization

CMS Pauses Medicare Home Health Pre-Claim Review Demonstration in Illinois, Puts Off Expanding Demo to Florida for Now

CMS has announced that it is “pausing” its Pre-Claim Review demonstration in Illinois for at least 30 days, effective April 1, 2017, and it is not expanding the demonstration to Florida in April as previously planned. During this pause period, Medicare contractors will not accept additional pre-claim review requests; instead, home health claims will be … Continue Reading

CMS Announces New Medicare Prior Authorization Requirements for Two Types of Power Wheelchairs

Beginning in March 2017, CMS is phasing in new Medicare prior authorization (PA) requirements for two types of power wheelchairs under a policy adopted in a final rule issued late in 2015. As previously reported, CMS finalized regulations to require Medicare PA for certain durable medical equipment (DME), prosthetics, orthotics, and supplies (DMEPOS) items that … Continue Reading

CMS Finalizes New Medicare Prior Authorization Rules for DMEPOS Subject to “Unnecessary Utilization,” But Policy Questions Remain

The Centers for Medicare & Medicaid Services (CMS) has issued a final rule to require Medicare prior authorization (PA) for certain durable medical equipment (DME), prosthetics, orthotics, and supplies (DMEPOS) items that the agency characterizes as “frequently subject to unnecessary utilization.” Notably, however, key policy decisions — including the items that will initially be subject … Continue Reading

CMS Expands Medicare Prior Authorization Model for Repetitive Scheduled Non-Emergent Ambulance Transport

As previously reported, CMS announced in November 2014 that it would test a Medicare prior authorization process for repetitive scheduled nonemergent ambulance transport services in New Jersey, Pennsylvania, and South Carolina. The three-year model began on December 1, 2014. As mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS is now … Continue Reading

CMS Schedules Provider Calls on Medicare Payment, Quality, Coding & Program Integrity Topics

CMS has scheduled a series of provider calls in February and March on the following topics: February 3: Special Open Door Forum on the upcoming Prior Authorization of Non-Emergent Hyperbaric Oxygen Therapy model to be implemented in March in Illinois, Michigan, and New Jersey. February 4: Special Door Forum on the introduction of star ratings on … Continue Reading

CMS to Conduct Hyperbaric Oxygen Prior Authorization Pilot Program

CMS intends to conduct a three-year Medicare prior authorization model for non-emergent hyperbaric oxygen therapy services in Illinois, Michigan, and New Jersey, where CMS contends there have been high rates of improper payments for these services. Under this model, CMS will require that all relevant clinical or medical documentation requirements are met before services are rendered … Continue Reading

CMS Announces 3-State Medicare Prior Authorization Model for Repetitive Nonemergent Ambulance Transport

In light of government reports finding high utilization and potential improper Medicare payments associated with repetitive scheduled nonemergent ambulance transports, CMS will test a prior authorization model program for these services in New Jersey, Pennsylvania, and South Carolina. CMS defines repetitive ambulance service as medically necessary ambulance transportation that is furnished in 3 round trips or … Continue Reading
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