Hospital Outpatient Departments: Effective July 1, 2020 you must request prior authorization for certain hospital Outpatient Department (OPD) services
For dates of service beginning July 1, 2020, you must request prior authorization for the following hospital Outpatient Department (OPD) services:
- Botulinum toxin injections (when paired with specific procedure codes)
- Vein ablation
Medical necessity documentation requirements remain the same and hospital OPDs will receive a decision within 10 days.
While only the hospital OPD service requires prior authorization, CMS wants to remind other providers that perform services in the hospital OPD setting that claims related to/associated with these services will not be paid if the service requiring prior authorization is not eligible for payment. These related services include, but are not limited to, anesthesiology services, physician services, and facility services. Only associated services performed in the hospital OPD setting are affected. Depending on the timing of claim submission for any related services, claims may be automatically denied, reviewed, or denied on a postpayment basis.
For botulinum toxin injections, consult the list of codes that require prior authorization for more details. Generally, the use of botulinum toxin injection codes paired with procedure codes other than 64612 or 64615 will not require prior authorization under this program.
- List of codes that will require prior authorization (PDF)
- Prior Authorization for Certain Hospital OPD Services webpage
- Operational Guide (PDF)
- FAQs (PDF)
- Final Rule: Page 61446