Prior Authorization and Pre-Claim Review Initiatives
The Centers for Medicare & Medicaid Services (CMS) runs a variety of programs that support efforts to safeguard beneficiaries’ access to medically necessary items and services while reducing improper Medicare billing and payments. Through prior authorization and pre-claim review initiatives, CMS helps ensure compliance with Medicare rules.
How they work
Prior authorization and pre-claim review are similar, but differ in the timing of the review and when services may begin. Under prior authorization, the provider or supplier submits the prior authorization request and receives the decision prior to rendering services. Under pre-claim review, the provider or supplier submits the pre-claim review request and receives the decision prior to claim submission; however, the provider or supplier can render services before submitting the request. A provider or supplier submits either the prior authorization request or pre-claim review request with all supporting medical documentation for provisional affirmation of coverage for the item or service to their Medicare Administrator Contractor (MAC). The MAC reviews the request and sends the provider or supplier an affirmed or non-affirmed decision.
Benefit to Providers and Suppliers
In an effort to reduce provider burden, these initiatives don’t change any medical necessity or documentation requirements. They require the same information that is currently necessary to support Medicare payment, just earlier in the process. This helps providers and suppliers address claim issues early and avoid denials and appeals. Prior authorization and pre-claim review have the added benefit of offering providers and suppliers some assurance of payment for items and services receiving a provisional affirmation decision.
Find out about the initiatives currently in place:
- Prior Authorization for Certain Hospital Outpatient Department (OPD) Services
- Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport
- Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items
- Review Choice Demonstration for Home Health Services
Learn about previous initiatives and their results: