Prior Authorization Update

Medicare has announced the inclusion of six (6) new Prosthetic codes in the Required Prior Authorization List. This means that these codes will be required to have a prior authorization from Medicare before being delivered in order to obtain Medicare payment.

If prior authorization is NOT obtained, Medicare will NOT pay the claim.

The new additional codes are L5856, L5857, L5858, L5973, L5980, and L5987.

Phase 1 of this rollout will include California, Michigan, Pennsylvania and Texas and will begin for dates of service on May 11, 2020. (Submissions to begin on April 27, 2020)

Phase 2 of this rollout will encompass the rest of the Nation and will begin for dates of service on October 8, 2020. (Submissions to begin on September 24, 2020)

Here is a link to get more info:

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

 

To enter Code Intelligence into OPIE:

1. Log into OPIE as an Administrative User

2. Click on Administrative Tools

3. Click the Office Settings tab

4. Click the Code Intelligence tab

5. In the Code field type L5856

6. In the Insurance field click the drop down and choose your Medicare payer

7. In the Rule Type field click the drop down and choose Documentation Required

8. Click the Create Rule button

9. Under Custom Message click the blue + box next to the drop down

10. Type the Custom Message to be used

Suggested message: Medicare Prior Authorization Required

11. Click the Add/Edit button at the bottom of the window

12. Click the Close button

13. Choose the custom message from the drop down

14. Click the Save & Close button

15. In the Code field use the drop down to select the next code

16.  The Insurance field should still be populated with your Medicare payer

17.  The Rule Type field should still be populated with Documentation Required

18.  Click the Create Rule button

19.  Click the drop down next to the Custom Message field and choose the message created in step 10 above

20.  Click the Save & Close button

21.  Repeat steps 15 through 20 for the next 4 codes (L5858, L5973, L5980 and L5987)

22.Click the Show All button

23.  You may sort your existing rules by any of the column headers to view them

NOTE: These steps may need to be repeated if you have more than one Medicare payer. If you have multiple Medicare payers, it may be less time consuming to use the import procedures outlined below.

To Import Code Intelligence into OPIE (template upload file to be found here)

1.  Modify template file

2.  Log into Code Intelligence

3.  Click the Import Rules button

4.  Navigate to the file saved in Step 1

5.  Click Open

6.  The Insurance Company Name Mappings window should appear. Use this window to ensure that you have correctly identified your Medicare payer (if you have more than one payer, you will repeat this step later for the next set of rules)

7.  Click the Apply button

8.  Click the Import button

9.  The Prepare for Import window will appear which will notify you of any problems with importing any of the rules

10. Click the With button

11. Code Rules should now be imported

Please feel free to contact OPIE Support if you have any questions or concerns or need assistance with this process.

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