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03/06/2017

"Condition of Payment Prior Authorization Program" for Certain DME Begins Today

On March 6, 2017, CMS is implementing a Condition of Payment Prior Authorization Program for certain DMEPOS items.  CGS Jurisdiction B and C will begin accepting Prior Authorization Requests (PAR) for the K0856 – Group 3 standard, single power option and K0861 – Group 3 standard multiple power option wheelchairs for dates-of-delivery on or after March 20, 2017.  The Condition of Payment Prior Authorization Program is eligible for Medicare beneficiaries residing in Illinois (Jurisdiction B – CGS), West Virginia (Jurisdiction C – CGS) and, Missouri (Jurisdiction D – Noridian), New York (Jurisdiction A – Noridian).

CGS is prepared for this change and we want to make sure you are as well.  Please share this important information with your members.

One important fact:  The Condition of Payment Prior Authorization Program is independent of the current Power Mobility Devices Prior Authorization Demonstration Program.  To help you understand the differences, CGS has created new website information which provides a table view of the differences between the two programs.  We have also provided access to the regulatory guidelines for the Condition of Payment Prior Authorization Program as well as documentation requirements, fax number, address and new coversheet.

Jurisdiction B Website:   http://www.cgsmedicare.com/jb/mr/condition_of_payment_prior_auth.html?wb48617274=32A0658E

Jurisdiction C Website:  http://www.cgsmedicare.com/jc/mr/condition_of_payment_prior_auth.html

Please note:  A provisional affirmation prior authorization decision is a condition of payment.  CMS is finalizing the provision to automatically deny payment for a claim for an item on the Required Prior Authorization List that is submitted without a provisional affirmation prior authorization decision. 

CGS is scheduling new education on the Condition of Payment Prior Authorization Program.  Please continue to monitor our website, subscribe to our ListServ and follow us on Facebook and Twitter for any new information regarding the Condition of Payment Prior Authorization Program.