CMS recently posted this data on its prior authorization program.[1]
Prior Authorization for Certain Hospital Outpatient Department (OPD) Services
The prior authorization program for certain hospital OPD services ensures that Medicare beneficiaries continue to receive medically necessary care while protecting the Medicare Trust Funds from unnecessary increases in the volume of covered services and improper payments. The Calendar Year (CY) 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center (OPPS/ASC) Final Rule (CMS -1717-FC) established a nationwide prior authorization process and requirements for certain hospital OPD services. These services are blepharoplasty, botulinum toxin injection, rhinoplasty, panniculectomy, and vein ablation. As part of the CY 2021 OPPS/ASC Final Rule (CMS -1736-FC), CMS added cervical fusion with disc removal and implanted spinal neurostimulators to the prior authorization process.
MAC Review Timeliness | |
---|---|
Average Number of Days | |
FY 21 |
4.3 |
FY 22 |
4.5 |
Appeals | |||||||
---|---|---|---|---|---|---|---|
Total Reviews Completed |
Total Reviews Affirmed |
Total Reviews Non-Affirmed |
Claims Appealed to Level 1 |
Level 1 Appeals: Overturned |
Level 1 Appeals: Upheld |
% Of Claims Overturned Out of Total Reviews Completed | |
FY 21 |
121,927 |
96,529 |
25,398 |
2,454 |
511 |
1,943 |
0.4% |
FY 22 |
132,565 |
104,144 |
28,421 |
1,886 |
419 |
1,467 |
0.3% |
OPD Providers Exempt from Prior Authorization[2] | |
---|---|
FY 21 |
165 |
FY 22 |
302 |
MAC Accuracy Rate |
98.1% FY21 |
98.5% FY22 |