Prior Authorization for Hospital Outpatient Department Services (HOPD) Overview
Need help?
Contact Us About Claims
Claim Status/Patient Eligibility:
(866) 518-3285
24 hours a day, 7 days a week
Claim Corrections:
(866) 518-3253
7:00 am to 4:30 pm CT M-Th
DDE Navigation & Password Reset: (866) 518-3251
7:00 am to 4:30 pm CT M-F
DDE System Access: (866) 518-3295
7:00 am to 4:30 pm CT M-F
EDI: (866) 518-3285
7:00 am to 5:00 pm CT M-F
General Inquiries:
(866) 518-3285
7:00 am to 5:00 pm CT M-F
Claim Status/Patient Eligibility:
(866) 234-7331
24 hours a day, 7 days a week
Claim Corrections:
(866) 580-5980
8:00 am to 5:30 pm ET M-Th
DDE Navigation & Password Reset: (866) 580-5986
8:00 am to 5:30 pm ET M-F
DDE System Access: (866) 518-3295
8:00 am to 5:30 pm ET M-F
EDI: (866) 234-7331
8:00 am to 5:00 pm ET M-F
General Inquiries:
(866) 234-7331
8:00 am to 5:00 pm ET M-F
Claim Status/Patient Eligibility:
(866) 518-3285
24 hours a day, 7 days a week
Claim Corrections/Reopenings:
(866) 518-3285
7:00 am to 5:00 pm CT M-F
EDI: (866) 518-3285
7:00am to 5:00 pm CT M-F
General Inquiries:
(866) 518-3285
7:00 am to 5:00 pm CT M-F
Claim Status/Patient Eligibility:
(866) 234-7331
24 hours a day, 7 days a week
Claim Corrections/Reopenings:
(866) 234-7331
8:00 am to 5:00 pm ET M-F
EDI: (866) 234-7331
8:00 am to 5:00 pm ET M-F
General Inquiries:
(866) 234-7331
8:00 am to 5:00 pm ET M-F
Need help?
General questions about Medical Review
- (866) 518-3285
7:00 am to 5:00 pm CT M-F
- (866) 234-7331
8:00 am to 5:00 pm ET M-F
- (866) 518-3285
7:00 am to 5:00 pm CT M-F
- (866) 234-7331
8:00 am to 5:00 pm ET M-F
Need help?
Contact Us About Overpayments
Inquiries regarding refunds to Medicare - MSP Related
(866) 518-3285
7:00 am to 5:00 pm CT (8:00 am to 5:00 pm ET) M-Fri
Secondary.Payer.Inquiry@wpsic.com
Inquiries regarding overpayments NOT associated with MSP
(866) 518-3285
7:00 am to 5:00 pm CT (8:00 am to 5:00 pm ET) M-Fri
Reimbursement.Overpayment.
Inquiry@wpsic.com
Inquiries regarding refunds to Medicare - MSP Related
(866) 234-7331
7:00 am to 5:00 pm CT (8:00 am to 5:00 pm ET) M-Fri
Secondary.Payer.Inquiry@wpsic.com
Inquiries regarding overpayments NOT associated with MSP
(866) 234-7331
7:00 am to 5:00 pm CT (8:00 am to 5:00 pm ET) M-Fri
Reimbursement.Overpayment.
Inquiry@wpsic.com
Questions regarding overpayments associated with MSP related debt
(866) 518-3285
7:00 am to 5:00 pm CT (8:00 am to 5:00 pm ET) M-Fri
Secondary.Payer.Inquiry@wpsic.com
Questions regarding overpayments NOT associated with MSP related debt
(866) 518-3285
7:00 am to 5:00 pm CT (8:00 am to 6:00pm ET) M-Fri
Payment.Recovery.Inquiry@wpsic.com
Questions regarding overpayments associated with MSP related debt
(866) 234-7331
7:00 am to 5:00 pm CT (8:00 am to 5:00 pm ET) M-Fri
Secondary.Payer.Inquiry@wpsic.com
Questions regarding overpayments NOT associated with MSP related debt
(866) 234-7331
8:00 am to 5:00 pm ET (7:00 am to 4:00pm CT) M-Fri
Payment.Recovery.Inquiry@wpsic.com
Need help?
Contact us about Appeals
7:00 am to 5:00 pm CT M-F
8:00 am to 5:00 pm ET M-F
7:00 am to 5:00 pm CT M-F
8:00 am to 5:00 pm ET M-F
Need help?
Contact Us About Provider Enrollment
(866) 518-3285
7:00 AM - 5:00 PM CT, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 234-7331
8:00 AM - 5:00 PM ET, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 518-3285
7:00 AM - 5:00 PM CT, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 234-7331
8:00 AM - 5:00 PM ET, Monday - Friday
USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
Need help?
Contact us about Policies
- (866) 518-3285 - General questions about Policies
7:00 am to 5:00 pm CT M-F
- (866) 234-7331 - General questions about Policies
8:00 am to 5:00 pm ET M-F
- (866) 518-3285 - General questions about Policies
7:00 am to 5:00 pm CT M-F
- (866) 234-7331 - General questions about Policies
8:00 am to 5:00 pm ET M-F
LCD Reconsideration Request: Policycomments@wpsic.com
Draft LCD Comments: Policycomments@wpsic.com
IDE Submissions: IDE.mailbox@wpsic.com
RSVP for Open Meeting and CAC: LCDCAC@wpsic.com
Questions about Payments and Incentive Programs
(866) 518-3285
7:00 am to 5:00 pm CT (8:00 am to 5:00 pm ET) M-F
Contact us about Form CMS-588 Electronic Funds Transfer (EFT)
(866) 518-3285
7:00 am to 5:00 pm CT (8:00 am to 5:00 pm ET) M-F
Financial.Reporting.Inquiry@wpsic.com
Do not submit PHI/PII through email
Questions about Payments and Incentive Programs
(866) 234-7331
7:00 am to 5:00 pm CT (8:00 am to 5:00 pm ET) M-F
Contact us about Form CMS-588 Electronic Funds Transfer (EFT)
(866) 234-7331
7:00 am to 5:00 pm CT (8:00 am to 5:00 pm ET) M-F
Financial.Reporting.Inquiry@wpsic.com
Do not submit PHI/PII through email
Questions about Payments, Fee Schedules, and Incentive Programs
(866) 518-3285
7:00 am to 5:00 pm CT (8:00 am to 5:00 pm ET) M-F
Contact us about Form CMS-588 Electronic Funds Transfer (EFT)
(866) 518-3285
7:00 am to 5:00 pm CT (8:00 am to 5:00 pm ET) M-F
Financial.Reporting.Inquiry@wpsic.com
Do not submit PHI/PII through email
Questions about Payments, Fee Schedules, and Incentive Programs
(866) 234-7331
7:00 am to 5:00 pm CT (8:00 am to 5:00 pm ET) M-F
Contact us about Form CMS-588 Electronic Funds Transfer (EFT)
(866) 234-7331
7:00 am to 5:00 pm CT (8:00 am to 5:00 pm ET) M-F
Financial.Reporting.Inquiry@wpsic.com
Do not submit PHI/PII through email
Need help?
Need help?
Mail audit materials:
WPS GHA
ATTN: Audit Supervisor
P.O. Box 8696
Madison, WI 53708-8696
When using a delivery service:
WPS GHA
ATTN: Audit Supervisor
1717 W. Broadway
Madison, WI 53713-1834
Mail audit materials:
WPS GHA
ATTN: Audit Supervisor
P.O. Box 14172
Madison, WI 53708-0172
When using a delivery service:
WPS GHA
ATTN: Audit Supervisor
1717 W. Broadway
Madison, WI 53713-1834
Need help?
Try these links first.
Questions about Self-Service?
(866) 518-3285
7:00 am to 5:00 pm CT M-F
Try these links first.
Questions about Self-Service?
(866) 518-3285
7:00 am to 5:00 pm CT M-F
Try these links first.
Questions about Self-Service?
(866) 234-7331
8:00 am to 5:00 pm ET M-F
Try these links first.
Questions about Self-Service?
(866) 234-7331
8:00 am to 5:00 pm ET M-F
Prior Authorization for Hospital Outpatient Department Services (HOPD) Overview
You currently have jurisdiction selected, however this page only applies to these jurisdiction(s): .
The PA program is applicable to HOPDs billing on a 13x type of bill in all US states and territories.
Effective June 17, 2020, for dates of service on or after July 1, 2020, CMS established a Prior Authorization (PA) program for the following services performed in a Hospital Outpatient Department (HOPD):
Effective June 17, 2021, for dates of service on or after July 1, 2021, CMS expanded the HOPD PA program to include two additional services:
Effective June 15, 2023, for dates of service on or after July 1, 2023, CMS expanded the HOPD PA program to include one additional service:
Before providing any of the services listed above, HOPDs must submit a PA request to their MAC.
Hospital Outpatient Departments that demonstrate compliance with Medicare coverage, coding, and payment rules related to prior authorization are eligible for exemption. Learn more.
Blepharoplasty, Blepharoptosis Repair, and Brow Ptosis Repair
Current Procedural Terminology (CPT) codes
Code | Description |
---|---|
15820 | Removal of excessive skin of lower eyelid |
15821 | Removal of excessive skin of lower eyelid and fat around eye |
15822 | Removal of excessive skin of upper eyelid |
15823 | Removal of excessive skin and fat of upper eyelid |
67900 | Repair of brow paralysis |
67901 | Repair of upper eyelid muscle to correct drooping or paralysis |
67902 | Repair of upper eyelid muscle to correct drooping or paralysis |
67903 | Shortening or advancement of upper eyelid muscle to correct drooping or paralysis |
67904 | Repair of tendon of upper eyelid |
67906 | Suspension of upper eyelid muscle to correct drooping or paralysis |
67908 | Removal of tissue, muscle, and membrane to correct eyelid drooping or paralysis |
Providers should include the following documentation with their blepharoplasty PA request:
- Patient complaints (difficulty reading, looking through eyelashes etc.)
- Pre-operative examination
- History and physical
- Visual fields with physician written interpretation
- Photographs (must include patient identifiers)
- Prior authorization requests should clearly identify which eye the request is for
- Any additional documentation indicating medical necessity of the planned procedure
See our Local Coverage Determination L34528 - Blepharoplasty, Blepharoptosis and Brow Lift for coverage criteria.
See the CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 , Section 120, for more information.
Botulinum Toxin Injection
Note: The provider should pair the injection code and the pharmaceutical code appropriately. Prior authorization requests are only for injection CPT codes 64612 and 64615.
Current Procedural Terminology (CPT) codes
Code | Description |
---|---|
64612 | Injection of chemical for destruction of nerve muscles on one side of face |
64615 | Injection of chemical for destruction of facial and neck nerve muscles on both sides of face |
J0585 | Injection, onabotulinumtoxina, 1 unit |
J0586 | Injection, abobotulinumtoxina |
J0587 | Injection, rimabotulinumtoxinb, 100 units |
J0588 | Injection, incobotulinumtoxin a |
Providers should include the following documentation with their botulinum toxin injections PA request:
- Documentation to support a covered diagnosis
- History and physical
- Planned dosage and frequency of the injection
- Prior authorization requests must include both the administration site and drug CPT codes
- Units of service for botulinum toxin injections should include the expected units of waste
- Physician progress notes supporting the results of the last two prior injections
- Prior procedure reports supporting 12 weeks between injections
- Documentation to support the patient has been unresponsive to conventional methods of treatments
- Documentation to support a history of migraines with occurrence most days of the month, if applicable
- Any additional documentation indicating medical necessity of the planned injection
See our LCD L34635 – Botulinum Toxin Type A & Type B for coverage criteria.
See the CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 , Section 120, for more information.
Panniculectomy, Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy), and Related Services
Current Procedural Terminology (CPT) codes
Code | Description |
---|---|
15830 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy |
15847 | Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (list separately in addition to code for primary procedure) |
15877 | Suction assisted removal of fat from trunk |
Providers should include the following documentation with their panniculectomy PA request:
- Progress notes supporting the decision to perform surgery
- History and physical
- Evidence of weight loss maintained for a minimum of 6 months, if applicable
- Evidence of chronic intertrigo (dermatitis, skin irritation, infection, chafing etc.) that remains refractory to medical treatments (dressing changes, topical antibiotics, oral antibiotics, corticosteroids, antifungals etc.) over a period of 3 months
- Any additional documentation indicating medical necessity of performing the surgery
See our LCD L39051 – Cosmetic and Reconstructive Services for coverage criteria.
See the CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 , Section 120, for more information.
Rhinoplasty, and Related Services
Current Procedural Terminology (CPT) codes
Code | Description |
---|---|
20912 | Nasal cartilage graft |
21210 | Repair of nasal or cheek bone with bone graft |
30400 | Reshaping of tip of nose |
30410 | Reshaping of bone, cartilage, or tip of nose |
30420 | Reshaping of bony cartilage dividing nasal passages |
30430 | Revision to reshape nose or tip of nose after previous repair |
30435 | Revision to reshape nasal bones after previous repair |
30450 | Revision to reshape nasal bones and tip of nose after previous repair |
30460 | Repair of congenital nasal defect to lengthen tip of nose |
30462 | Repair of congenital nasal defect with lengthening of tip of nose |
30465 | Widening of nasal passage |
30520 | Reshaping of nasal cartilage |
Providers should include the following documentation with their rhinoplasty PA request:
- Progress notes supporting the decision to perform surgery
- Documentation to support a nasal obstruction
- Documentation to support deficits / structural deformities produced by trauma or nasal cutaneous disease
- Documentation to support the rhinoplasty was to replace nasal tissue lost after tumor ablative surgery
- Any additional documentation indicating medical necessity of performing the surgery
Additional information about prior authorization requests for rhinoplasty can be found in Prior Authorization for Rhinoplasty and Septoplasty.
See our LCD L39051 – Cosmetic and Reconstructive Services for coverage criteria.
See the CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 , Section 120, for more information.
Vein Ablation, and Related Services
Current Procedural Terminology (CPT) codes
Code | Description |
---|---|
36473 | Mechanochemical destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance |
36474 | Mechanochemical destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance |
36475 | Destruction of insufficient vein of arm or leg, accessed through the skin |
36476 | Radiofrequency destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance |
36478 | Laser destruction of incompetent vein of arm or leg using imaging guidance, accessed through the skin |
36479 | Laser destruction of insufficient vein of arm or leg, accessed through the skin using imaging guidance |
36482 | Chemical destruction of incompetent vein of arm or leg, accessed through the skin using imaging guidance |
36483 | Chemical destruction of incompetent vein of arm or leg, accessed through the skin using imaging guidance |
Providers should include the following documentation with their vein ablation PA request:
- History and physical examination supporting the diagnosis of symptomatic varicose veins and the failure of an adequate (at least 3 months) trial of conservative management
- Diagnostic test results, if medically necessary, to confirm the pathology of the vascular anatomy
- Documentation detailing the reason for each vein treatment
- Documentation of reflux and vein diameter
- Prior procedure reports including date and treatment location
- Prior authorization requests should clearly identify which extremity and vein(s) the request is for
- Any addition documentation indicating the medical necessity of the planned procedure
Additional information regarding PA requests for Vein Ablation and Related Services can be found in Prior Authorization for Vein Ablation and Related Services in a Hospital Outpatient Department.
See our LCD L34536 – Treatment of Varicose Veins for coverage criteria.
See the CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 , Section 120, for more information.
Cervical Fusion with Disc Removal
Current Procedural Terminology (CPT) codes
Code | Description |
---|---|
22551 | Fusion of spine bones with removal of disc at upper spinal column, anterior approach, complex, initial |
22552 | Fusion of spine bones with removal of disc in upper spinal column below second vertebra of neck, anterior approach, each additional interspace |
Providers should include the following documentation with their cervical fusion with disc removal PA request:
- Condition requiring procedure
- Physical examination
- Duration/character/location/radiation of pain
- Activity of daily living (ADL) limitations
- Imaging reports pertinent to performed procedure
- Operative report(s), when applicable
- Conservative treatment modalities that include but are not limited to:
- Physical therapy
- Occupational therapy
- Injections
- Medications
- Assistive device use
- Activity modification
Additional information regarding PA requests for cervical fusion with disc removal can be found in Prior Authorization for Cervical Fusion with Disc Removal Performed in a Hospital Outpatient Department.
Implanted Spinal Neurostimulators (Spinal Cord Stimulators)
Current Procedural Terminology (CPT) codes
Code | Description |
---|---|
63650 | Implantation of spinal neurostimulator electrodes, accessed through the skin |
Providers should include the following documentation with their Implanted Spinal Neurostimulators PA request:
Implanted Spinal Neurostimulators (Spinal Cord Stimulators) trial or permanent
- Indication if the request is for a trial or permanent placement
- Condition requiring procedure
- Physical examination
- Treatment tried and failed including but not limited to:
- Spine surgery
- Physical therapy
- Medications
- Injections
- Psychological therapy
- Documentation of appropriate psychological evaluation
Implanted Spinal Neurostimulators (Spinal Cord Stimulators) permanent
- Include all of the above documentation, as well as documentation of pain relief with the temporary implanted electrode(s)
- A successful trial should be associated with at least 50% reduction of target pain or 50% reduction of analgesic medications
Additional information regarding PA requests for Implanted Spinal Neurostimulators can be found in Prior Authorization of Implantation of Spinal Neurostimulators.
See the CMS Internet-Only Manual (IOM) Publication 100-03, Medicare National Coverage Determination, Chapter 1, Part 2 Coverage Determinations, Section 160.7 – Electrical Nerve Stimulators, for more information.
Facet Joint Interventions
Current Procedural Terminology (CPT) codes
Code | Description |
---|---|
64490 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level |
64491 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level |
64492 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) |
64493 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level |
64494 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level |
64495 | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) |
64633 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint |
64634 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint |
64635 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint |
64636 | Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint |
Providers should include the following documentation with their Facet Joint Interventions PA request:
- History and physical
- Physician orders and progress notes
- Diagnostic test results
- Procedure records
- Pain history to include location, severity, and duration
- Evidence of failed conservative management
- Disability scale rating for each new episode of pain
- Patient response to prior facet joint interventions, if applicable
- Medical history records
- Signature attestation form, if applicable
See our LCD L38841 – Facet Joint Interventions for Pain Management for more information.
Prior Authorization Request and Documentation Submission
We encourage providers to use the WPS Government Health Administrators Portal or esMD to submit documentation. However, providers may submit their documentation via postal mail, encrypted CD/DVD/flash drive, or secure fax. All CD/DVDs/flash drives must be password protected. Please email the password and the tracking number (if applicable) to MR.ADR.Passwords@wpsic.com.
To be valid the prior authorization request must:
- Include the facility PTAN and NPI
- Include the correct Medicare Beneficiary Identifier (MBI)
- Include medical documentation for review
- Include an applicable CPT or HCPCS code
- Be legible
To help expedite the review process, complete the Hospital Outpatient Department (OPD) Prior Authorization (PA) Request Form and place it on top of your medical record documentation.
Mail or fax your request and documentation to the appropriate address or fax number below:
J5 MAC Address | J5 National Address | If Using a Delivery Service | Fax Number |
---|---|---|---|
WPS Government Health Administrators Medical Review PO Box 7953 Madison, WI 53707-7953 |
WPS Government Health Administrators Medical Review PO Box 7957 Madison, WI 53707-7957 |
WPS Government Health Administrators Medical Review 1717 W. Broadway Madison, WI 53713-1834 |
(608) 327-8516 |
J8 MAC Address | If Using a Delivery Service | Fax Number |
---|---|---|
WPS Government Health Administrators Medical Review PO Box 7954 Madison, WI 53707-7954 |
WPS Government Health Administrators Medical Review 1717 W. Broadway Madison, WI 53713-1834 |
(608) 327-8517 |
Prior Authorization Request Review Process
Upon receipt of a PA request, the MAC has 10 business days to review and issue a decision (affirmed or non-affirmed). The MAC will send a detailed letter to the requester with the decision. The letter will include a Unique Tracking Number (UTN) that the Part A HOPD provider must submit on the claim. The claims processing system will reject claims submitted without a UTN even if an affirmed decision is on file. Part B physicians do not need to include it on their claims.
Providers may submit expedited requests if the standard timeframe for making a decision could seriously jeopardize the life or health of the beneficiary. We will screen expedited requests upon receipt. A Nurse Analyst will make a decision on the validity of the expedited request. If the expedited request is valid, a Nurse Analyst will issue a decision within 2 business days. If the expedited request is invalid, we will convert the request to a standard request.
If the decision is non-affirmed the provider may resubmit the PA request. Resubmission requests should include the prior UTN and documentation to correct the non-affirmed decision.
The UTN issued is valid for one-time use for 120 days from the date of the prior authorization decision. A new UTN is not required if the anticipated date of service changes as long as it is within 120 days.
Prior Authorization for Services Performed In The Emergency Room
In the event that the place of service for a procedure requiring a PA is the HOPD emergency room WPS will issue a retroactive decision. The HOPD should submit a PA request to the MAC within two business days. The HOPD should mark the PA request as expedited with a reason of emergency room place of service. WPS will review the PA request and issue a decision within two business days.
Prior Authorization Program General Resources
- 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center (OPPS/ASC) Final Rule (CMS-1717-FC)
- 2021 Outpatient Prospective Payment System/Ambulatory Surgical Center (OPPS/ASC) Final Rule (CMS-1736-FC)
- Prior Authorization (PA) Program for Certain Hospital Outpatient Department (OPD) Services Operational Guide
- Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services Frequently Asked Questions
global-tags: Featured Guides and Resources,J8A,J5A,Surgery,Claim Review,Prior Authorization,Injections
Need help?
General questions about Medical Review
- (866) 518-3285
7:00 am to 5:00 pm CT M-F
- (866) 234-7331
8:00 am to 5:00 pm ET M-F
- (866) 518-3285
7:00 am to 5:00 pm CT M-F
- (866) 234-7331
8:00 am to 5:00 pm ET M-F
.
View AMA License
LICENSE FOR USE OF PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (CPT)
End User Point and Click Agreement:
CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).
You, your employees and agents are authorized to use CPT only as contained in the following authorized materials of Centers for Medicare and Medicaid Services (CMS) internally within your organization within the United States for the sole use by yourself, employees and agents. Use is limited to use in Medicare, Medicaid or other programs administered by CMS. You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60654. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt.
Applicable FARS\DFARS Restrictions Apply to Government Use. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60654. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.
AMA Disclaimer of Warranties and Liabilities.
CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this agreement.
CMS Disclaimer
The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT should be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.
Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking above on the button labeled "Accept".
LICENSE FOR USE OF CURRENT DENTAL TERMINOLOGY (CDT™)
These materials contain Current Dental Terminology (CDTTM), Copyright © 2010 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.
THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING ABOVE ON THE BUTTON LABELED "ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.
IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.
IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.
- Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
- Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org/.
- Applicable Federal Acquisition Regulation Clauses (FARS)\Department of restrictions apply to Government Use. Please click here to see all U.S. Government Rights Provisions.
- ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT IS PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND, EITHER EXPRESSED OR IMPLIED, INCLUDING BUT NOT LIMITED TO, THE IMPLIED WARRANTIES O F MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE. NO FEE SCHEDULES, BASIC UNIT, RELATIVE VALUES OR RELATED LISTINGS ARE INCLUDED IN CDT. THE ADA DOES NOT DIRECTLY OR INDIRECTLY PRACTICE MEDICINE OR DISPENSE DENTAL SERVICES. THE SOLE RESPONSIBILITY FOR THE SOFTWARE, INCLUDING ANY CDT AND OTHER CONTENT CONTAINED THEREIN, IS WITH (INSERT NAME OF APPLICABLE ENTITY) OR THE CMS; AND NO ENDORSEMENT BY THE ADA IS INTENDED OR IMPLIED. THE ADA EXPRESSLY DISCLAIMS RESPONSIBILITY FOR ANY CONSEQUENCES OR LIABILITY ATTRIBUTABLE TO OR RELATED TO ANY USE, NON-USE, OR INTERPRETATION OF INFORMATION CONTAINED OR NOT CONTAINED IN THIS FILE/PRODUCT. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third party beneficiary to this Agreement.
- CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. IN NO EVENT SHALL CMS BE LIABLE FOR DIRECT, INDIRECT, SPECIAL, INCIDENTAL, OR CONSEQUENTIAL DAMAGES ARISING OUT OF THE USE OF SUCH INFORMATION OR MATERIAL.