Special Open Door Forum: Prior Authorization Process for Certain DMEPOS: Required Prior Authorization of Pressure Reducing Support Surfaces

Centers for Medicare & Medicaid Services Special Open Door Forum:

Prior Authorization Process for Certain DMEPOS:

Required Prior Authorization of Pressure Reducing Support Surfaces

Tuesday, June 4, 2019

2:00 pm-3:30 pm Eastern Time

Conference Call Only

The Center for Program Integrity (CPI) will host a Special Open Door Forum (ODF) to invite Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers, physicians and other Medicare stakeholders to discuss the addition of Pressure Reducing Support Surfaces (PRSS) to the Required Prior Authorization List.

As announced in the Federal Register Notice 84 FR 16616, published on April 22, 2019, CMS has added the following five Healthcare Common Procedure Coding System (HCPCS) codes to the list of DMEPOS items that require prior authorization as a condition of payment:

• E0193 Powered air flotation bed (low air loss therapy)
• E0277 Powered pressure reducing air mattress
• E0371 Nonpowered advance pressure reducing overlay for mattress length and width
• E0372 Powered air overlay for mattress, standard mattress length and width
• E0373 Nonpowered advanced pressure reducing mattress

Prior authorization for PRSSs will be implemented in two phases. Phase I will begin July 22, 2019. Prior authorization will be limited to one state in each of the four DME Medicare Administrative Contractor (MAC) jurisdictions as follows: California, Indiana, New Jersey, and North Carolina. Phase II will begin October 21, 2019 and expands prior authorization of these codes to the remaining states and territories.

The Special ODF will include a discussion on the process for submitting a prior authorization request to the designated MAC, the timeframes for the MAC to render their prior authorization decisions, and the subsequent claim submission process. 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.

Prior authorization helps ensure all relevant coverage, coding, and clinical documentation requirements are met before the item is furnished and before the claim is submitted for payment. Prior authorization also certifies that payment of DMEPOS items is appropriate, thereby working toward the prevention and identification of potential fraud, waste and abuse; the protection of the Medicare Trust Funds from improper payments; and the reduction of Medicare appeals.

This link will take you to our DMEPOS Prior Authorization page where slides will be posted in advance of the ODF: www.go.cms.gov/DMEPOSPA

You can find the Federal Register Notice here.

Feedback and questions for the Required Authorization for Pressure Reducing Support Surfaces and other DMEPOS items can be sent to: DMEPOSPA@cms.hhs.gov

We look forward to your participation.

Special Open Door Participation Instructions:

Participant Dial-In Number: 5960428

Conference ID #: 1-800-837-1935

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 Podcast and Transcripts website at https://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/PodcastAndTranscripts.html 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.