Prior auth update: No involvement from ATP trips some providers

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Friday, April 28, 2017

WASHINGTON – CMS gave insight into how providers are doing with a new prior authorization process for two complex rehab codes during the third in a series of Special Open Door Forums on April 25.

During the forum, Dr. Robert Hoover, the chief medical officer for CGS Administrators, the DME MAC for Jurisdictions B and C, cited top non-affirmation reasons for K0856 and K0861 so far. An issue that has popped up in both jurisdictions: no evidence that an ATP had direct, in-person involvement in the selection of the power mobility device.

A number of other non-affirmation reasons deal with the face-to-face exam: it was not signed by the treating practitioner (Jurisdiction B); it was incomplete (B); and it did not paint a clear picture of the beneficiary’s functional abilities and limitations (C).

Other reasons are: there was no indication of receipt date by supplier for documentation (B); there was no financial attestation stating the licensed/certified medical professional has no financial relationship with the supplier (C); and the 7-element order was not written by the same physician/practitioner who completed the face-to-face exam (C).

Top rejection reasons in Jurisdiction B are duplicate request, rep payee on file and wrong jurisdiction; and in Jurisdiction C, beneficiary not in program state and faxing error.

In two previous forums, CMS officials spent the bulk of their time discussing whether or not accessories are covered under the process. That topic came up again during this third forum, when a caller said she was still confused. Hoover reiterated that accessories will be reviewed as part of affirming or non-affirming a device, but they will not, technically, be part of the affirmation or non-affirmation. The caller asked when providers will know if accessories have been approved, and Hoover said when they submit a claim for payment.

CMS kicked off the prior authorization process in four states on March 6. It began accepting prior authorization requests for dates of delivery on or after March 20.