Ronda Says: Are You Ready for Oct. 21? Group II Support Surfaces Enter Prior Authorization Program for All States

Published in Billing, Reimbursement, Audits and Compliance on October 15, 2019

CMS announced in Dec. 30, 2015 a finalized rule creating a program called Condition of Payment Prior Authorization Program for Certain DMEPOS items. The program includes two different lists, one is titled the “Master List,: and consists of 135 HCPCS codes. The codes on the Master list include E1390, E0466, E2402 and all Group II Support Surface codes that could potentially be on the required a prior authorization list. The second list is called the “Required Prior Authorization List.” This list includes the HCPCS codes that where on the Master List but now moved to the required prior authorization. When CMS determines to move codes to Required Prior Authorization List, there must be a minimum of 60 days prior to implementation to the healthcare community.

In September 2018, the program went nationally for 33 power mobility device (PMD) HCPCS codes (K0813- K0856, K0861). In April 2019, CMS announced that they will be adding seven more PMD codes to Required Prior Authorization List which are K0857-K0863 that began nationally on July 22, 2019. The announcement also included the five Group II Support Surfaces which are E0193, E0277, E0371, E0372, E0373. With Group II Support Surfaces, it will be implemented in two phases. Phase 1 already began on July 22, 2019 in the following four states (one in each Jurisdiction) New Jersey - Noridian Jurisdiction A, North Carolina - CGS Jurisdiction C, Indiana – CGS Jurisdiction B, and California – Noridian Jurisdiction D.

Phase 2 will be implemented nationally in ALL states beginning on Oct. 21, 2019. Suppliers can start submitting PA on Oct. 7 for date of service (DOS) of Oct. 21.

Here are a few key items to be attentive of for the PA program:

  • For initial dates of service (DOS), a PA is not needed on items currently renting under capped rental payment
  • Applies to Medicare FFS Primary and Medicare FFS Secondary
  • Decision will be made within five days of receipt of all applicable information
  • May submit for expedited request, which is a two-day turnaround. This can only be done if jeopardizing the life or health of the beneficiary
  • Five-day turnaround for any resubmission with an unlimited amount of resubmissions
  • No submission of a PA means a denial, however, appeal rights are an option
  • Even though an affirmation has been issued, there may still be a denial (or audit) based on technical requirements that can only be evaluated after a claim is submitted for processing
  • PA process DOES NOT change medical policy requirements (LCD and related policy article)
  • Must complete the Face Sheet that is applicable to the Jurisdiction to send with documentation

Prior Authorization is a something we need to wrap our arms around because it is a good process and has been effective for the PMD category. DMEPOS suppliers must start changing thought processes to being more proactive than reactive. This means to educate referral sources on this requirement so the transition from an inpatient facility to home will be smooth as well as educate referrals to implement with their pressure ulcer treatment protocol to engage the DME Supplier upon admission in order to get the PA process started.

See COPPA rules and the Master List of HCPCS codes.

Ronda BuhrmesterFor further questions, please reach out to Ronda Buhrmester, Senior Director of Payer Relations and Reimbursement at [email protected] or 217-493-5440.

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