Outpatient Department Prior Authorization (PA)

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 requested 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 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). 

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 PA Program for Certain Hospital OPD Services Operational Guide (PDF).

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

Resources

• CMS Prior Authorization for Certain Hospital OPD Services web page
• CMS PA Program for Certain Hospital 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 OPD Services Frequently Asked Questions (PDF)
• CMS MAC website list
• Helping You Complete the OPA Request Form Video
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