Prior authorization helps Ambulatory Surgical Center (ASC) providers ensure that their services comply with applicable Medicare coverage, coding, and payment rules before services are rendered and before claims are submitted for payment.

Prior authorization does not create new clinical documentation requirements. Instead, it requires the same information that is already required to support Medicare payment, just earlier in the process. Prior authorization allows providers to address issues with claims prior to rendering services and submitting claims for payment, which has the potential to reduce appeals for claims that may otherwise be denied.

Prior authorization for the ASC demonstration is voluntary. However, if a provider elects to bypass prior authorization, applicable ASC claims will be subject to a prepayment medical review. CMS believes prior authorization for certain ASC services will ensure that Medicare beneficiaries continue to receive medically necessary care – while protecting the Medicare Trust Fund from improper payments and, at the same time, keeping the medical necessity documentation requirements unchanged for providers.

The service categories targeted by the demonstration are: 

• Blepharoplasty
• Botulinum toxin injections
• Panniculectomy
• Rhinoplasty
• Vein ablation

Download the full list of HCPCS codes for prior authorization (PDF).