Prior Authorization for L0648, L0650, L1832, L1833 and L1851

Medicare is implementing a prior authorization process for specific back brace and knee brace HPCPC codes. The process will be rolled out in three phases. (See “Prior Authorization for Specific Orthoses” for more details).

CMS released the details involved in the prior authorization process. In general, the prior authorization process involves:

1. Submitting a Prior Authorization Request (PAR) to the appropriate DME MAC through the provider portal.
2. Include all necessary documentation with the PAR
   -Patient Information
   -Supplier Information
   -WOPD (see “Written Order Prior to Delivery”)
   -Face to Face Examination within 6 months by treating physician and DMEPOs supplier
   -Supporting medical record documentation, including any specific requirements outlined in the LCDs.

Upon receipt, the DME MACs will review the PAR request and provide an initial decision within five business days. Affirmative PAR decisions will remain in effect for 60 days. Providers receive a Unique Tracking Number (UTN) once the PAR is approved. Include the UTN on the claim form. (For electronic submissions this 14-byte UTN number is listed in the 2300 or 2400 service loop).

In the case a PAR is denied, the DME MAC provides information about what is missing. The provider may submit another PAR request with the missing information.

What Does This Mean for You?

Become familiar with the Prior Authorization Process. All DMEPOS jurisdictions are offering several webinars on the Prior Authorization of Orthoses. Sign up for the webinars at Jurisdiction A/D or Jurisdiction B/C.

Know the phased rollout plan and identify when you are required to be using the Prior Authorization process.

Confirm enrollment with the appropriate DME MAC provider portal for ease of submission.