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Prior Authorization Process for Certain Durable Medical Equipment, Prosthetic, Orthotics, Supplies (DMEPOS) Items

Update 03/30/18:

As announced in the Federal Register, CMS has provided the annual update to the Master List of DMEPOS items that the Secretary determined, on the basis of prior payment experience, are frequently subject to unnecessary utilization. As noted in CMS 6050-F, we adjust the Payment Threshold each year for inflation. This update does not reflect any additions because there are no new items that meet the updated Payment Threshold that are listed in an OIG or GAO report of a national scope or a CERT DME and/or DMEPOS Service Specific Report(s). This update removes the following four HCPCS codes from the Master List because they no longer meet the Payment Threshold: E0260, E0601, E1390, and K0004. The full updated list is available in the Downloads section below.  

Update 06/28/17:

As originally announced in the Federal Register (here), published on December 21, 2016, CMS is preparing for the nationwide expansion of the prior authorization process for the first two items of durable medical equipment to be subject to required prior authorization beginning on July 17, 2017:

  • K0856: Power wheelchair, group 3 std., single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
  • K0861: Power wheelchair, group 3 std., multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

Suppliers or beneficiaries submitting the first claims in the series for these items must receive prior authorization before the item is furnished or a claim is submitted, as a condition for payment. DME MACs will begin accepting prior authorization requests for this expansion beginning July 3, 2017.

The CMS will host the fourth in a series of Special Open Door Forums to invite suppliers, physicians, practitioners, and other interested parties to discuss the prior authorization process. CMS will outline the process for submitting a prior authorization request to the designated DME MAC and the process for subsequent submission of prior authorized claims. DMEPOS suppliers and other participants are encouraged to submit questions and provide feedback that may be incorporated into our supporting documents, such as frequently asked questions or the operational guide. This Special Open Door Forum is scheduled for Thursday, July 6, 2017 at 2:00 p.m. More information will be available here. CMS will post slides in the ‘Downloads’ section below in advance of the call.

For more information about the prior authorization process specific to these items, stakeholders may access support materials in the ‘Downloads’ section below.

Update 4/21/17:

The CMS will host the third in a series of Special Open Door Forums to invite suppliers, physicians, practitioners, and other interested parties to discuss the coverage and documentation requirements for K0856 and K0861, which are the first two codes selected as part of the prior authorization process for certain items of DMEPOS. The Chief Medical Officer for CGS, the Jurisdiction C DME MAC, will present on the coverage and documentation requirements.

This Special Open Door Forum is scheduled for Tuesday, April 25, 2017 at 2:00 p.m. More information will be available here.

Update 3/15/17:

CMS has posted additional resources for suppliers, physicians, and their patients on the new subpages on the menu on the left. These include introductory letters, frequently asked questions, and a flow chart of the prior authorization process. There is also a chart displaying the special tracking and education process for prior authorization review requests that are not approved due to submissions that include documentation errors but where the patient seems to otherwise meet Medicare’s coverage criteria. Suppliers submitting documentation with these errors will receive individualized education and are encouraged to resubmit their request to ensure patients continue to receive the necessary covered services.

CMS will host the first in a series of DMEPOS Special Open Door Forum calls on Thursday, March 16, 2017 at 2:00PM Eastern Time, for DMEPOS suppliers. As announced previously in the Federal Register, CMS has selected two items to be subject to prior authorization under the Prior Authorization of Certain DMEPOS Items program (Group 3 power wheelchairs - K0856 and K0861). On this call, we will outline the process for submitting a prior authorization request to your designated Durable Medical Equipment Medicare Administrative Contractor (DME MAC), the timeframes for the DME MAC to render their prior authorization decisions, and the process for subsequent claim submissions. DMEPOS suppliers and other participants will be encouraged to submit questions and provide feedback that may be incorporated into our supporting documents, such as frequently asked questions or the operational guide. CMS will post slides in the ‘Downloads’ section below in advance of the call. Click here for more information on this Special Open Door Forum.

CMS will host a separate DMEPOS Special Open Door Forum call for physicians and other Medicare practitioners on Tuesday, March 21, 2017 at 2:00PM Eastern Time. CMS will post more information on that call soon.

Welcoming Feedback to Support Program Transparency while Empowering Patients and Providers

CMS is committed to launching the narrowly tailored Prior Authorization Program of Certain DMEPOS Items program in an open and transparent manner that serves and protects patients and the health care providers that care for them.  CMS has the opportunity to learn from patient and provider experience and welcomes feedback as a critical part of this process.  We look forward to an ongoing dialogue to help us gather feedback and learn how the program can best meet patients’ needs. 

To enhance this dialogue with both patients and providers, and to support program transparency, CMS will soon be launching a new website for DMEPOS Prior Authorization with helpful tools for patients, suppliers, and physicians. These patient-centered resources aim to improve transparency; protect access to care; and support direct engagement with patients, suppliers, and physicians. CMS will begin adding these new resources to this website starting on or before March 20, 2017. CMS will contract with an independent evaluator to fully analyze the impacts of prior authorization, including effects on patient care; access to services; or the patient, supplier, or physician/practitioner experience.

Please note that all initial prior authorization decisions should be made in no more than 10 days. In cases where that timeframe could seriously jeopardize the life or health of the beneficiary, you may request an expedited review. Decisions for substantiated expedited reviews should be made within 2 business days.

CMS has established a dedicated mailbox to solicit feedback from all stakeholders as this program gets underway. We encourage patients and providers to address all feedback to: DMEPOSPA@cms.hhs.gov.

Through this mailbox, CMS is also seeking feedback on how the current medical necessity criteria for power wheelchairs aligns with documentation requirements. Is a supplier able to accurately assess whether the patient meets the medical necessity criteria? How can the documentation requirements associated with the coverage decision be improved? One of the resources CMS will soon post is a Provider Checklist for Prior Authorization of Power Wheelchairs. CMS would like feedback on the checklist, and whether it helps suppliers, physicians, and practitioners understand what information is needed for Medicare to pay for the item.

Prior Authorization Request Submission Process

Suppliers who are ready to submit a prior authorization request for a date of service of March 20, 2017 or later can use the operational guide in the Downloads section to access necessary information and processes.

Update 12/19/16:

CMS announced in the Federal Register (here), as published on December 21, 2016, the selection of two items of durable medical equipment to be subject to required prior authorization beginning on March 20, 2017:

  • K0856: Power wheelchair, group 3 std., single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
  • K0861: Power wheelchair, group 3 std., multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds

Suppliers or beneficiaries submitting claims in one of the 4 states listed below must receive prior authorization before the item is furnished or a claim is submitted, as a condition for payment:

  • Illinois
  • Missouri
  • New York
  • West Virginia

CMS also announced its intent to expand the prior authorization process for codes K0856 and K0861 nationwide in July 2017.

For information about the prior authorization process specific to these items, stakeholders may access support materials in the download section below.

Watch this site for more information about upcoming provider calls to share additional information about this program.

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