CMS’s Prior Authorization Process and Requirements for Certain Outpatient Hospital Department Services

CMS will begin the process of requiring prior authorization for certain outpatient hospital department services starting July 1, 2020. Certain services within the blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation categories will require prior authorization when traditional (Fee-for-Service) Medicare is the payer. But, not all codes for these services fall under the requirement for prior authorization. CMS has provided a list of procedure codes requiring prior authorization that can be accessed here

CMS has initiated the prior authorization for certain services because their analysis indicated a significant increase in the utilization volume of some covered outpatient department services. CMS is targeting services that likely represent cosmetic surgical procedures that are not covered by Medicare.

Medicare Administrative Contractors (MAC) began processing prior authorizations on June 17 for services to be performed on or after July 1, 2020. Providers submit their prior authorization request to their respective MAC. Check with your MAC to determine requirements for submission. Prior authorization decisions are to be issued by the MAC within ten (10) business days; however, there is an option to request expedited reviews when necessary.

During their open door forum call on May 28, CMS made it clear that the prior authorization process is for hospital outpatient department (OPD) services only. Services provided in physician’s offices, critical access hospitals, or ambulatory surgery centers will not require prior authorization. CMS also expects the hospital OPD, rather than the physician’s office, to be the submitter of the request. Only the OPD is required to submit the prior authorization number, called a unique tracking number (UTN), on the claim.

MACs will be reviewing the submitted prior authorization request against published Local Coverage Determinations (LCDs), so be sure to review your LCDs related to these services before submitting for the prior authorization. For those hospital systems that span more than one MAC, remember that different LCDs can have different requirements for the same services. Medicare Advantage (MA) plans do not have to follow CMS’s prior authorization program for these services. But, I suspect most MA plans already require prior authorization or will start if they don’t already.

Once the MAC has reviewed the prior authorization request, they will issue a provisional affirmation decision, partial affirmation decision, or a non-affirmation decision. The MAC will send the hospital OPD provider a written decision with detailed reasons for the non-affirmation decision, which will also be shared with beneficiaries. The OPD will have an opportunity to resubmit the request with additional information. If a provisional affirmation is granted, it is good for 120 days. For now, if a patient is undergoing a series of procedures, such as Botox injection every 12 weeks, each new procedure will require a new prior authorization request.

One thing that is clear in this new process is that if a claim for a service that requires prior authorization is denied, presumably because the OPD did not request prior authorization or prior authorization was denied, and the service was provided anyway, the associated services will also be denied. Associated services could be anesthesiology services, physician services, and/or facility services.

AHDAM is interested in hearing about your experience with this new prior authorization process. Please email me at with the good, the bad, and the ugly of your experiences so we can share them with the community.

For More Information:

• Final rule –

• Prior Authorization webpage: Presentation materials posted prior to the call –


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Denise serves as the Senior Vice President at Denial Research Group – AppealMasters. Denise is also President of The Association for Healthcare Denial and Appeal Management. Denise is a Registered Respiratory Therapist, Registered Nurse, and holds a Master’s degree in Management Information Systems from the University of Illinois, Springfield.

Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing. Denise has extensive experience as a Medical Appeals Expert and has personally managed hundreds of Medicare, Managed Medicare, and Commercial appeal cases and presented hundreds of cases at the Administrative Law Judge level.

Denise is a nationally known speaker and dynamic educator on Medicare and Commercial appeals processes, payer behaviors, standards of care, appeal template development, and building a road map to drive the payer to a decision in the provider’s favor. She has educated thousands of healthcare professionals around the country in successfully overturning medical care denials.