Special Open Door Forum: Prior Authorization Process for National Expansion of the First 2 Items for Prior Authorization Certain DMEPOS:

Centers for Medicare & Medicaid Services
Special Open Door Forum:

Prior Authorization Process for Certain DMEPOS:
National Expansion of the First 2 Items for Prior Authorization

Thursday, July 6, 2017

2:00-3:00 PM Eastern Time

Conference Call Only

CPI will host a Special Open Door Forum (ODF) to invite suppliers, physicians, and other Medicare practitioners or interested parties to discuss the nationwide expansion of the prior authorization process for the first two items of Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS). 

As announced in the Federal Register Notice 6072, as published on December 21, 2016, CMS selected two DMEPOS items, represented by HCPCS (Healthcare Common Procedure Coding System) codes K0856 and K0861, for prior authorization in Illinois, Missouri, New York, and West Virginia, when furnished on or after March 20, 2017. In this notice, CMS also announced its intent to expand the prior authorization process for these codes nationwide. These power wheelchairs, if furnished on or after July 17, 2017, will require prior authorization as a condition of payment for beneficiaries in all remaining states and US territories not included in the first phase of the program.

This announcement follows CMS’ final rule establishing a prior authorization process for certain DMEPOS items that are frequently subject to unnecessary utilization. The rule, as published in late December 2015, provided a Master List of 135 DMEPOS items frequently subject to unnecessary utilization and the criteria for their inclusion on the Master List, subject to annual updates. The rule specified that presence on the Master List does not automatically create a prior authorization requirement for that item. Rather, CMS selects items from the Master List to be subject to prior authorization as a condition for payment. The selected items are included on what is known as the Required Prior Authorization List, and must be publically announced through Federal Register Notice. K0856 and K0861 are the first two items added to the Required Prior Authorization List.

We will outline the process for submitting a prior authorization request to the designated Medicare Administrative Contractor (MAC), the timeframes for the MAC to render their prior authorization decisions, and the process for subsequent claim submissions.  Participants will be encouraged to submit questions or provide feedback that may be incorporated into our supporting documents, such as the frequently asked questions document or the operational guide.

CMS is committed to launching the DMEPOS Prior Authorization Program in an open and transparent manner that serves and protects patients and the health care providers that care for them.  CMS has the opportunity to learn from patient and provider experience and welcomes feedback as a critical part of this process.  We look forward to an ongoing dialogue to help us gather feedback and learn how the program can best meet patients’ needs. 

Here is the link to our Prior Authorization Initiatives page where slides will be posted in advance of this ODF, as well as frequently asked questions, a fact sheet, and an operational guide in the downloads section: 

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Prior-Authorization-Process-for-Certain-Durable-Medical-Equipment-Prosthetic-Orthotics-Supplies-Items.html

You can find the final rule by going to: https://www.gpo.gov/fdsys/pkg/FR-2015-12-30/pdf/2015-32506.pdf.

You can find the federal register notice announcing the first two items subject to prior authorization under this process, here: https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-30273.pdf.

We look forward to your participation.

Special Open Door Participation Instructions:

Participant Dial-In Number: 1-800-837-1935

Conference ID #: 37139406

Note: TTY Communications Relay Services are available for the Hearing Impaired. For TTY services dial 7-1-1 or 1-800-855-2880. A Relay Communications Assistant will help.

A transcript and audio recording of this Special ODF will be posted to the Special Open Door Forum website at http://www.cms.gov/OpenDoorForums/05_ODF_SpecialODF.asp for downloading.

For automatic emails of Open Door Forum schedule updates (E-Mailing list subscriptions) and to view Frequently Asked Questions please visit our website at http://www.cms.gov/opendoorforums/ .

Thank you for your interest in CMS Open Door Forums.