Medicare Pre Authorization for LLP

Effective for dates of service December 1, 2020, the Medicare pre-authorization program for 6 specific HCPCS codes will begin for all DMEPOS suppliers.

You and your staff need to familiarize yourself with this process and plan to submit preauthorization for any claims containing one or more of the following HCPCS codes:

• L5856
• L5857
• L5858
• L5973
• L5980
• L5987

What is the pre authorization process?

Any claim which includes one or more of the above HCPCS, for dates of service December 1, 2020 and after,  must have pre authorization from the appropriate DME MAC.

• The pre-authorization submission must include the SWO, medical records, and corroborating documentation.
• The DME MAC has 10 business days to review the request.
• Authorization letters will be sent to the mailing address on file with the NSC
• Once you receive authorization, you have 120 calendar days to provide the service.
• If the pre-authorization request is denied, you may resubmit
• You will receive a Unique Tracking Number (UTN) which must then be included on the submitted claim.

Register with your DME MAC to utilize the online pre-authorization submission:

• www.cgsmedicare.com  - Region B, Region C
• www.noridianmedicare.com  - Region A, Region D

When can I start submitting for pre authorization?

All suppliers may start submitting requests for pre authorization on November 17, 2020. You must follow the process outlined in your DME MAC site (see above links.) This means the DME MAC has 10 business days to respond and you will be able to provide the appropriate product and services to your patients on or after December 1, 2020.

What documents will be reviewed?

•  A Standard Written Order (SWO) which includes:
• Patient’s Name
• Order Date
• General Description of the item(s)
• Prescribing physicians name and signature
• Physician’s Medical Records, which must include sufficient detail to support the patient’s functional capabilities.
• Prosthetist’s Medical Records, which also must include sufficient detail to support the patient’s functional capabilities.

What other resources are available?

Review the Local Coverage Determination LCD33787

Check with your DME MAC for more information on upcoming webinars

Check the PDAC site, www.dmepac.com, to verify the product is listed with the appropriate HCPCS.

What Does This Mean For You? 

There are three key takeaways from the coding verifications published so far. First, the initial results for the already-reviewed prosthetic feet suggest that the coding guidance for L5980, L5981 and L5987 published earlier this year by the DME MACs in the Policy Article for Lower Limb prostheses is reshaping the base codes applicable to prosthetic feet. Specifically, it appears that many feet historically coded as L5980 and L5987 will be reclassified into the L5981 code. Second, based on the initial verifications, we believe that many feet historically coded with L5984 and/or L5986 will lose these add-on codes when verified by PDAC, as it looks like PDAC is taking a narrower view of what L5984 and L5986 describe. Third, PDAC’s review process is ongoing. You should be checking the PDAC’s website daily to confirm whether any new products have been added to the verification list. Once there, we recommend the following: 

1. Click on the “Product Classification List” button. 
2. Enter the applicable HCPCS code. 
3. When the results table appears, click on the “Effective Begin Date” heading so that results get organized from newest to oldest. 
4. Repeat for each of the other 5 HCPCS codes subject to prior authorization.  

We will continue to keep you apprised of results over the next several months from time to time.  

For more information or assistance with your reimbursement questions, please contact us at [email protected].