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CMS announces guidelines for prostheses

CMS announces guidelines for prostheses Decisions on initial prior auth requests will be made within 10 business days

WASHINGTON - CMS has issued guidance for its new prior auth program for lower limb prostheses and sought to reassure providers that it would closely monitor implementation.

CMS officials during a Special Open Door Forum March 11 also sought to reassure participants that, for the most part, it will be business as usual.

“The policy hasn't changed and the way the DME MACs will review these claims will be exactly the way we've done so over the last few years,” said one official.

Among the new guidelines discussed during the call:

• Decisions on initial prior auth requests will be made within 10 business days of receiving the initial request, as will decisions on prior auth resubmissions.

• Decisions on expedited prior auth requests—where the beneficiary's life or health is in immediate danger—will be made within two business days.

• Prior auth requests may be submitted through multiple channels, including electronic submission, through the DME MAC claim portal, by fax and by mail.

For the four states included in phase one, set to kick off May 11, the DME MACs will begin accepting prior auth requests on April 27; for national implementation, the DME MACs will being accepting requests on Sept. 24.

The top concern for O&P stakeholders on the call was ensuring that timely access for beneficiaries is not delayed.

“We're grateful for the two-day expedited review, and the 10-business day review if that deadline is actually met,” said one caller. “It's not optimal but not unreasonable. What happens if the experience by providers is that those timed deadlines are not adhered to and patients are delayed in the care they receive?”

CMS and the DME MACs will be monitoring the program, say officials.

“We certainly have thought of this,” said one official. “In our other PA programs, the MACs come well within the 10-day timeframes. That hasn't been a problem and we take that very seriously.”




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