Hospitals may want to distribute this form to physicians to enlist their help with Medicare’s prior authorization program for five hospital outpatient procedures, which takes effect July 1,[1] said Ronald Hirsch, M.D., vice president of R1 RCM, who developed the form. Physicians also will be hit in the wallet for denied procedures, CMS says. Contact Hirsch at rhirsch@r1rcm.com.
Applicable to:
Medicare Fee-For-Service Insurance (Primary or Secondary)—Hospital Outpatient Department
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Blepharoplasty
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Botulinum Toxin Facial Injections
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Panniculectomy
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Rhinoplasty
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Vein Ablation
Beneficiary Information
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First and last name
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Medicare Beneficiary Identifier—MBI
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Gender
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Date of Birth
Physician Information
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Name
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National Provider Identifier—NPI
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CMS Certification Number
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Office Address
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Phone Number
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Fax Number
Procedure Information
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Anticipated Date of Service
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All Planned HCPCS Codes
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ICD-10-CM Diagnosis Code(s)
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Units of Service
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Paired Code(s) for Botulinum Toxin Injections
Medical Records (See Procedure-Specific Requirements)
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Documentation Supporting Medical Necessity
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Photographs
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Reports of any Applicable Imaging or Diagnostic Tests