Prior Authorization of Power Mobility Devices (PMDs) Demonstration

This demonstration began for orders written on or after September 1, 2012. The CMS first announced the demonstration on November 15, 2011. To be responsive to comments received from the public, CMS decided to delay the demonstration and make improvements. The CMS believes this demonstration will lead to reductions in improper payments for power mobility devices, which will help ensure the sustainability of the Medicare Trust Funds and protect beneficiaries who depend upon the Medicare program. In addition, this demonstration is designed to develop and demonstrate improved methods for the investigation and prosecution of fraud in the provision of care or services under the health programs established by the Social Security Act.

The DME MACs in Jurisdiction C and D began accepting prior authorization requests through esMD beginning January 7, 2013.  The other DME MACs will begin accepting prior authorization requests through esMD later in winter 2013. In order to submit a prior authorization request through esMD, providers must choose a CMS-certified Health Information Handler (HIH) that offers prior authorization documentation submission services.  To see a list of which HIHs offer this service, click the link called “HIHs that offer Prior Auth submission services” in the 'Related Links' section below.

CMS has become aware of a very limited number of claims inappropriately denied even though they received an affirmative prior authorization decision tracking number. If suppliers believe they are affected, please contact your DME MAC to address the issue.  CMS and its contractors take these issues seriously and will work to correct issues brought to our attention. We apologize for any inconvenience this may have caused.

CMS and the DME MACs strive to provide detailed explanations for non-affirmative prior authorization decisions. As CMS considers future enhancements, CMS and the DME MACs have created a draft list of reason statements to provide a narrative explanation of the non-affirmative decision.  CMS welcomes comments regarding these 'Proposed Reason Statements' which are available in the Downloads section below.  Please send your comments to reasonstatements@cms.hhs.gov

Demonstration Description

The CMS implemented a Prior Authorization process for scooters and power wheelchairs for people with Fee-For-Service Medicare who reside in seven states with high populations of fraud- and error-prone providers (CA, IL, MI, NY, NC, FL and TX). In addition to the benefits mentioned above, this demonstration will help ensure that a beneficiary's medical condition warrants their medical equipment under existing coverage guidelines. Moreover, the program will assist in preserving a Medicare beneficiary's ability to receive quality products from accredited suppliers. For more information about the demonstration see "Fact Sheet: General Information" in the Downloads section below.

Modifications Made After Initial November 15, 2011 Announcement 

The CMS received many comments/suggestions on the Prior Authorization of PMDs demonstration after it was announced in 2011. The CMS has considered these comments carefully. Answers to some frequently asked questions are available at go.cms.gov/PAFAQ2012 keyword PMD.

In response to comments received from stakeholders, the CMS has made a number of modifications to the Prior Authorization of PMD demonstration:

• The CMS has completed a separate Paperwork Reduction Act (PRA) notification for this demonstration and the Recovery Audit Prepayment Review demonstration. The demonstration was delayed until OMB PRA control number was obtained. 
• The CMS has removed the 100% Pre-Payment review phase (formerly Phase 1). All modifications that had previously been made to Phase 1, are no longer necessary or applicable as a result of the removal this phase.
• The CMS now allows suppliers to perform the administrative function of submitting the prior authorization request on behalf of the physician/practitioner.
• The CMS reduced the review time on resubmissions to 20 business days from 30.

For more information about these modifications see "Summary of Demonstration Modifications" in the Downloads section below.

Office of Management and Budget (OMB) PRA Control Number

The CMS received an OMB control number 0938-1169 associated with the information collection for this demonstration. The CMS displayed a Federal Register (FR) Notice on August 1, 2012 announcing the start date of the demonstration (see Downloads below). The start date of the demonstration is based on the date of the written order.

Education and Outreach

The CMS conducted extensive education and outreach before the demonstration to clarify all demonstration requirements to ordering physicians, practitioners, suppliers and beneficiaries. The CMS will continue educate and engage the provider and supplier communities throughout the demonstration. 

Helpful Educational Documents

• Physicians/Practitioners may find it helpful to review the Common Pitfalls document in the PMD documentation in the Downloads section below.
• For more operational details about the demonstration please see the PMD Operational Demonstration Guide in the Downloads section below.

Please continue to check this web site for updated information.

If you have any questions regarding this demonstration please e-mail: PAdemo@cms.hhs.gov

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