Heart of Health Policy | CMS Announces Details on Prior Authorization of Specific Elective Hospital Outpatient Services

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The Centers for Medicare and Medicaid Services (CMS) has announced details of specific elective services performed in the hospital outpatient department as included in the prior authorization program established by the 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (CMS-1717-FC).

Beginning July 1, services requiring prior authorization will include vein ablation, blepharoplasty, botulinum toxin injections, panniculectomy and rhinoplasty. The full list of HCPCS (1st ref) codes requiring prior authorization is available on the CMS website. This prior authorization requirement is limited to services rendered in the hospital outpatient department only.

Regional Medicare Administrative Contractors (MACs) will administer the prior authorization program, which consists of developing the approval criteria, processing the authorization requests, and notifying the requestors and patients of the results.

Currently, MACs must complete their review and determination within 10 business days. There is an additional option for an "expedited" determination, which will be completed within two business days.

The ACC encourages members performing these services to review the CMS Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services presentation slide deck and OPD Operational Guide on the CMS Prior Authorization website for registration information and guidance on the program.

Keywords: ACC Publications, Cardiology Magazine, Health Policy, Healthcare Common Procedure Coding System, Centers for Medicare and Medicaid Services (U.S.), Medicare, Blepharoplasty, Prior Authorization, Rhinoplasty, Outpatients, Medicaid, Abdominoplasty, Prospective Payment System, Lipectomy, Hospital Departments, Botulinum Toxins


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