Rejected Prior Authorization Request

The request was submitted to the incorrect Medicare Administrative Contractor (MAC)

The MAC is typically based where the outpatient department (OPD) is located

Submit the request to the correct MAC responsible for processing requests for the state where the OPD is located

The beneficiary has a Medicare Advantage Plan or Medicaid

This program applies to Medicare fee-for-service beneficiaries

Contact the individual Medicare Advantage or Medicaid Plan for information on their prior authorization requirements

The request contains an invalid/missing/deceased Medicare Beneficiary Identifier (MBI), or beneficiary name

Providers must include certain data elements in a prior authorization request to be processed

Submit a new request with the corrected information

The beneficiary already has an affirmed prior authorization on file for the same service(s)

Each UTN is valid for 120 days. Each procedure requires a new prior authorization request regardless of whether the next service falls within 120 days.

Adjust the information on your prior authorization request and submit the request again. Note: If a PAR is for an additional procedure and date of service is within 120 days, please indicate this on the PAR.

Invalid or missing OPD billing information (PTAN, NPI, TOB code)

Only hospital outpatient department services require prior authorization as part of this program. Other facility/provider types (e.g., physician’s offices, critical access hospitals, ambulatory surgery centers that submit claims other than type of bill 13X) are not required to submit prior authorization requests.

Verify the hospital outpatient department required information and resubmit the prior authorization request

The PAR for permanent neurostimulator was submitted, but there is an affirmed PAR on file for a trial procedure for the same OPD and physician

Providers who plan to perform both the trial and permanent implantation procedures using CPT 63650 at the same hospital OPD are only required to submit a PAR for the trial procedure

To avoid a claim denial, place the UTN received for the trial procedure on the claim submitted for the permanent implantation procedure

The PAR was submitted from an exempt provider

Exempt providers do not need to submit prior authorization requests

Render the service and follow your standard billing process

The PAR was missing a Botulinum toxin administration or drug code

PARs for Botulinum toxin services must contain both an administration code (64612 or 64615) and a drug code (J0585, J0586, J0587 or J0588)

Verify HCPCS code pairs and resubmit if the procedure codes are 64612 or 64615 and the drug codes are J0585, J0586, J0587 or J0588

The PAR was submitted with no clinical documentation

The PAR must include medical record documentation to demonstrate compliance with Medicare coverage, coding and payment rules

Submit a new request with medical record documentation for review