Outpatient Department Prior Authorization (PA)

Published 06/15/2021

The Centers for Medicare & Medicaid Services (CMS) has established a nationwide prior authorization (PA) process and requirements for certain hospital outpatient department (OPD) services. This process serves as a method for controlling unnecessary increases in the volume of these services and to ensure that medical necessity is met. 

Effective for dates of service on or after July 1, 2020, prior authorization must be requested for the hospital OPD claim for the following services:

  • Blepharoplasty
  • Botulinum toxin injections
  • Panniculectomy
  • Rhinoplasty
  • Vein ablation

CMS has added two new services to the hospital OPD PA program. For dates of service on and after July 1, 2021, PA will be required as a condition of payment for the following hospital OPD services:

  • Cervical Fusion with Disc Removal
  • Implanted Spinal Neurostimulators

Providers can submit an OPD PA request for these new services as early as June 17, 2021, for dates of service on or after July 1, 2021.

The full list of procedure codes that require PA for OPD services can be found in Appendix A of the CMS Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational Guide (PDF, 522 KB).

Submitting an OPD Prior Authorization Request for a Railroad Medicare Patient

The OPD PA process applies to Part A hospital OPDs that submit claims with Type of Bill (TOB) 13X and are paid under the Outpatient Prospective Payment System (OPPS). Prior authorizations requests for Railroad Medicare patients should be submitted to the jurisdictional Medicare Administrative Contractor (MAC) that will process the hospital’s outpatient department facility claim. No PA requests should be submitted to Palmetto GBA Railroad Medicare. Consult your local MAC’s website for additional OPD PA resources and requirements. The CMS OPD Operational Guide (PDF, 522 KB) contains a list of Contact Information for each MAC. You may also use the CMS MAC Website List to find the website of your jurisdictional MAC.

Part B Claims for Associated/Related Services 

Claims for services associated with or related to a service that requires OPD PA as a condition of payment will not be paid if the hospital’s OPD claim for the service requiring PA is not paid, received a non-affirmation decision and/or was denied. Associated services include but are not limited to, anesthesiology services, physician services, and/or facility services. This only applies to associated services performed in a hospital outpatient department setting. The full list of Part B associated codes can be found in Appendix B of the Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational Guide (PDF, 522 KB).

See the CMS Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services Frequently Asked Questions (PDF, 229 KB) for more information about the processing of associated/related services. 

Resources

  • CMS Prior Authorization for Certain Hospital Outpatient Department (OPD) Services web page 
  • CMS Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational Guide (PDF, 522 KB)
    • Appendix A — 2021 Final List of Outpatient Department Services That Require Prior Authorization
    • Appendix B — OPD PA Part B Associated Codes List
  • CMS Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services Frequently Asked Questions (PDF, 229 KB)
  • CMS MAC website list