Outpatient Department Prior Authorization (PA)

Published 12/07/2023

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

For dates of service on and after July 1, 2021, prior authorization must be reuqested for the hospital OPD claim for the following services:

  • Cervical Fusion with Disc Removal
  • Implanted Spinal Neurostimulators

For dates of service on or after July 1, 2023, prior authorization must be requested for the hospital OPD claim for the following services:

  • Facet Joint Interventions

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). The list of procedure codes for Facet Joint Interventions can be found in Change Request 13016 (PDF).

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).

See the CMS Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services Frequently Asked Questions (PDF) 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)
    • Appendix A — 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)
  • CMS MAC website list

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