Sub-Regulatory Guidance to Play Major Role in Prior Authorization

WASHINGTON, D.C. (January 7, 2016)—On December 29, 2015, CMS published the final rule to Medicare Program: Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies. This comes a year and a half after the proposed rule, which came out on May 28, 2014. Originally CMS proposed that the timeframe for a response to a prior authorization request would be made within 10 days or two days for expedited requests. In July 2014, AAHomecare commented that prior authorization decisions must be completed within 24 hours or two hours for expedited requests in order to meet patient needs.

AAHomecare was pleased to learn that CMS will not be finalizing the proposed time frames. CMS also announced the DMEPOS items and the start date of the prior authorization program have also not been finalized but all of this information will be provided in the sub-regulatory guideline which will be published sometime in the foreseeable future. The DMEPOS items that will be eligible for prior authorization are based on data that showed a high rate of fraud or over utilization and payment threshold of an average purchase fee of at least $1,000 or an average monthly rental fee schedule of at least $100. The item list that was presented in the original proposal was changed to include an addition of oxygen concentrator (E1390) and removal of the following items:

• Custom shaped protective cover, above knee (L5705)
• Custom shaped protective cover, knee disarticulation (L5706)
• Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control (L5718)
• Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control (L5722)
• Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock (L5816)

However, not all items on the 135-item list will be subject to having a prior authorization requirement. CMS will determine which items out of the list will be required to have a prior authorization and will publish it in the sub-regulatory guideline.

You may find AAHomecare’s summary of the Final Rule at this link. Visit aahomecare.org for more information.