35045 *35045* Medicare Part D Prior Authorization Request Form (page 1 of 2) Please complete both pages and return to Medco by fax at 1-800-837-0959. Please indicate if you are requesting urgent processing
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Let's talk about the newly released pre-authorization rule from Medicare according to CMS the OIG Gao and cert reports from 2007 and later indicate the documentation errors do not trend toward specific suppliers but that the root cause of improper payments is a lack of appropriate documentation what do we know right now about the ruling CMS estimates the per case time burden of preauthorization will be the same as for prepayment review 30 minutes per submission where do they come up with the 30 minute guideline that's because they assume you have all the doctors notes prior to submitting any claim we also know that 84 L codes are on the list of potential preauthorization items response times according to the ruling will be 10 days for an initial submission and 20 days for resubmits we know that some audit protection will be afforded to claims that have been pre-authorized we also know that preauth will be focused on specific L codes not on specific suppliers so it will be applied to all whether you have a good billing history with Medicare or not what we don't know right now about the rule is the date for implementation that's right CMS has published the final rule but has decided not to start implementation yet they will give a 60-day notice when they come up with a date we also don't know which of the 84 L codes will be required to have preauthorization CMS States they want to implement this rule gradually and so we'll choose only some of the codes and might only implement it in certain geographic areas CMS appears to be on a different page than piano again luckily in the body of the pre-authorization rule they've provided some insight into their position I leave you to chew on this quote from the published rule we will be closely monitoring utilization and billing practices the benefits include it changed billing practice that also enhances the cord nation of care for the beneficiary for example requiring preauthorization for certain items requires that the primary care provider and the supplier collaborate more frequently to order and deliver the most appropriate DMEPOS item meeting the needs of the beneficiary improper payments made because the practitioner did not order an item or evaluate the patient would likely be reduced by the requirement that a supplier submit clinical documentation created by the practitioner ie the doctor as part of its pre authorization request it's a good idea to review the entire ruling and here's the address where you can find it online you