CMS Letter on Prior Authorization for Hospital Outpatient Procedures

In an April 24 Medicare Transmittal (10061),[1] CMS revealed that Medicare administrative contractors (MACs) will run the new prior authorization process for five outpatient procedures, which starts July 1, and published a letter that providers and physicians will be receiving. The transmittal indicates CMS has no plans to delay the prior authorization process because of the COVID-19 public health emergency, at least for now, said Ronald Hirsch, M.D., vice president of R1 RCM. “But it tells us nothing about what the MACs will use to determine medical necessity or if CMS will provide checklists or guidelines other than national coverage determinations if available,” he noted. Contact Hirsch at rhirsch@r1rcm.com.

PROVIDER NAME

PROVIDER ADDRESS

CITY ST ZIP

Mail Date (ex. June 1, 2020)

Provider NPI Number: Provider NPI

Dear Provider:

The purpose of this letter is to inform you that the Centers for Medicare & Medicaid Services (CMS) has implemented a Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services furnished on or after July 1, 2020, nationwide.

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