Prior Authorization for Certain Hospital Outpatient Department (OPD) Services
Through the Calendar Year 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (CMS-1717-FC), CMS established a nationwide prior authorization process and requirements for certain hospital outpatient department (OPD) services. This process serves as a method for controlling unnecessary increases in the volume of these services.
CMS believes prior authorization for certain hospital OPD 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 following hospital OPD services will require prior authorization when provided on or after July 1, 2020:
- Botulinum toxin injections
- Vein ablation
The full list of HCPCS codes requiring prior authorization is available here (PDF). CMS will post additional information about this program on this website.