Prior Authorization for Certain Hospital Outpatient Department (OPD) Services Terminology

To ensure your success with Outpatient Department Prior Authorization, there are some terms you should know.

PAR — Prior Authorization Request: A request that is submitted before the service is provided to the beneficiary, and before the claim is submitted for processing. The PAR must include all documentation necessary to show that the service meets applicable Medicare coverage, coding and payment rules.

Initial Submission: The first PAR sent to the contractor for review and decision. The Medicare Administrative Contrctor (MAC) will complete its review of medical records and will send an initial decision letter that is delivered through eServices or esMD, postmarked or faxed within 10 business days following the receipt of the initial request. A copy of the decision letter will also be mailed to the beneficiary.

Resubmission: Any subsequent resubmissions to correct an error or omission identified during a PA decision. A resubmitted PAR is a request submitted with additional and/or updated documentation after the initial PAR was non-affirmed. The MAC will deliver the decision letter to the provider through eServices or esMD or postmarked or faxed within 10 business days of receipt of the resubmission request. A copy of the decision letter will also be mailed to the beneficiary.

UTN — Unique Tracking Number: A 14-byte number assigned to each request which indicates that the submitter requested a prior authorization; this number will be used for corresponding claim submissions.

Provisional Affirmation: A preliminary finding that a future claim submitted to Medicare for the service(s) likely meets Medicare’s coverage, coding and payment requirements. This decision is valid for 120 calendar days from the date decision was made.

Non-Affirmation: A preliminary finding that if a future claim is submitted to Medicare for the requested service, it likely does not meet Medicare’s coverage, coding and payment requirements. The MAC will notify the requestor via fax, mail, or eServices as to what required documentation is missing or noncompliant with Medicare requirements.

Partial Affirmation: One or more service(s) on the PAR received a provisional affirmation decision and one or more service(s) received a non-affirmation decision.

eServices: A secure, internet-based, self-service portal. Palmetto GBA’s goal is to give providers secure and fast access to their Medicare information seamlessly via our website through the eServices portal.