Medicare Program; Extension of Medicare Prior Authorization for Power Mobility Devices (PMDs) Demonstration
Notice.
Citation: "80 FR 41503"
Document Number: "CMS-6057-N2"
Page Number: "41503"
"Notices"
SUMMARY: This notice announces an extension of the Medicare Prior Authorization for Power Mobility Devices (PMDs) demonstration.
DATES: This demonstration will now end 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
On
The objective of the demonstration is to develop improved methods for the investigation and prosecution of fraud in order to protect the Medicare Trust Funds from fraudulent actions and any resulting improper payments. The demonstration's extension will continue to provide the agency with valuable data through which the agency, working with its partners, can develop new avenues for combating the submission of fraudulent claims to the
* Suppliers who no longer bill or have a significant decrease in billing during the demonstration.
* 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 original demonstration states decreased after
II. Provisions of the Notice
This notice announces the extension of the Medicare PMDs demonstration for an additional 3 years, until
This notice will serve as notification of the extended demonstration. In addition, we will publicize the extended demonstration through postings to our Web site and tweets.
CMS or its agents will continue to conduct outreach and education including webinars, state meetings, and other educational sessions as appropriate. Updated information will be posted to the CMS Web site (http://go.cms.gov/PADemo). We will also continue to work to limit the impact on
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 any other clinical documentation that is necessary to determine medical necessity regardless of which entity is functioning as the submitter. The supplier must also complete 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 subsequently 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
* Scenario 3: A submitter sends a prior authorization request where documentation is incomplete. The DME MAC sends back the prior authorization request to the submitter with an explanation about what information is missing and notifies the physician or treating practitioner, supplier, and
* Scenario 4: An applicable PMD claim is submitted without a prior authorization decision or the DME supplier fails to submit a prior authorization request, but nonetheless delivers the item to the
++ If the claim is determined to be not medically necessary, or insufficiently documented, the claim will be denied. The supplier or
++ If the claim is determined to be payable, it will be paid. However, a 25-percent reduction in the
If the prior authorization request is not affirmed, and the claim is submitted by the supplier, the claim will be denied.
Additional information is available on the CMS Web site (http://go.cms.gov/PADemo).
III. Collection of Information Requirements
This notice announces the extension of the Medicare PMDs Demonstration and does not impose any new information collection burden under the Paperwork Reduction Act of 1995. However, there is an information collection burden associated with the demonstration that is currently approved under OMB control number 0938-1169 which expires
IV. Regulatory Impact Statement
This document announces an extension of the Medicare PMDs Demonstration. Therefore, there are no regulatory impact implications associated with this notice.
Dated:
Acting Administrator,
[FR Doc. 2015-17365 Filed 7-14-15;
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