Medicare Program; Expanded Medicare Prior Authorization for Power Mobility Devices (PMDs) Demonstration
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SUMMARY: This notice announces the expansion of the Medicare Prior Authorization for Power Mobility Devices (PMDs) Demonstration to 12 additional states.
DATES: This expanded demonstration begins on
FOR FURTHER INFORMATION CONTACT:
Questions regarding the Medicare Prior Authorization for Power Mobility Device Demonstration should be sent to [email protected].
SUPPLEMENTARY INFORMATION: Section 402(a)(1)(J) of the Social Security Amendments of 1967 (42 U.S.C. 1395b-1(a)(1)(J)), authorizes the Secretary to conduct demonstrations designed to develop or demonstrate improved methods for the investigation and prosecution of fraud in the provision of care or services provided under the
Data we will analyze will include the following:
* Suppliers who no longer bill or have a significant decrease in billing.
* Physicians/treating practitioners with a high volume of submissions.
* Codes that show a dramatic increase in use.
Based on preliminary data collected, spending per month on PMDs in the seven demonstration states decreased after
II. Provisions of the Notice
Because of the initial success of the demonstration in reducing spending on PMDs, we are expanding the demonstration to 12 additional states (
Prior to the start of the expanded demonstration, contractors and the public will be notified about the expansion. This notice will serve as notification in addition to Web site postings and tweets.
CMS or its agents will continue to conduct outreach and education including webinars, in-state meetings, and other educational sessions in the additional states as appropriate. Updated information will be posted to the CMS Web site (http://go.cms.gov/PADemo). We will also work to limit the impact on
Under the expanded demonstration, we will continue to follow the policies and procedures that are currently in place for the demonstration. In accordance with current demonstration policy, a request for prior authorization and all relevant documentation to support the medical necessity along with the written order for the covered item must be submitted when one of the following Healthcare Common Procedures Coding System (HCPCS) codes for a PMD is ordered:
* Group 1 Power Operated Vehicles (K0800 through K0802 and K0812).
* All standard power wheelchairs (K0813 through K0829).
*
*
* Pediatric power wheelchairs (K0890 and K0891).
* Miscellaneous power wheelchairs (K0898).
Under this demonstration, a physician, treating practitioner or supplier may submit the prior authorization request and all relevant documentation to support
In order to be affirmed, the request for prior authorization must meet all applicable rules, policies, and National Coverage Determination (NCD)/Local Coverage Determination (LCD) requirements for PMD claims. The LCD documentation requirement mandates that the physician or treating practitioner shall complete the seven element order, face-to-face encounter, and whatever other clinical documentation that is necessary to determine medical necessity regardless of which entity is functioning as the submitter. The supplier completes the detailed product description (DPD) regardless of which entity is functioning as the submitter.
After receipt of all relevant documentation, CMS or its agents will make every effort to conduct a complex medical review and postmark the notification of their decision with the prior authorization number within 10 business days. Notification is provided to the physician/treating practitioner, supplier, and the
If the prior authorization request is not affirmed, and the claim is submitted by the supplier, the claim will be denied.
Submitters may also request expedited reviews in emergency situations where a practitioner indicates clearly, with supporting rationale, that the standard (routine) timeframe for a prior authorization decision (10 days) could seriously jeopardize the beneficiary's life or health. The expedited request must be accompanied by the required supporting documentation for this request to be considered complete thus commencing the 48-hour review. Inappropriate expedited requests may be downgraded to standard requests. After conducting an expedited review, CMS or its agents will communicate a decision for the prior authorization request to the submitter within 48 hours of the complete submission.
The following explains the various prior authorization scenarios:
* Scenario 1: A submitter sends a prior authorization request to the DME MAC with appropriate documentation and all relevant
* Scenario 2: A submitter sends a prior authorization request, but all relevant
--This is a summary of a
Notice.
Citation: "79 FR 44038"
Document Number: "CMS-6057-N"
Federal Register Page Number: "44038"
"Notices"
Copyright: | (c) 2014 Federal Information & News Dispatch, Inc. |
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