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CMS: Special Open Door Forum re: Prior Authorization Process

February 28, 2020

Prior Authorization Process for Certain Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) Items: Inclusion of Lower Limb Prosthetics (LLPs) in Prior Authorization

Wednesday, March 11th, 2020

2:00-3:00 PM Eastern Time

Conference Call Only

The CPI will host a Special Open Door Forum to invite suppliers, physicians, and other Medicare practitioners or interested parties to discuss the implementation of required prior authorization (PA) for six lower limb prosthetic (LLP) items of DMEPOS.

As announced in the Federal Register Notice 6080-N-3, as published on February 11, 2020, the CMS has selected six DMEPOS items, represented by HCPCS (Healthcare Common Procedure Coding System) codes L5856, L5857, L5858, L5973, L5980, and L5987, for prior authorization in California, Michigan, Pennsylvania, and Texas for dates of service on or after May 11, 2020. In this notice, the CMS also announced its intent to expand the prior authorization process for these codes nationwide. These lower limb prosthetics, if furnished on or after October 8, 2020, will require prior authorization as a condition of payment for beneficiaries in all remaining states and US territories.

We will outline the process for submitting a prior authorization request to the designated Medicare Administrative Contractor (MAC), the timeframes for the MAC to render their prior authorization decisions, and the process for subsequent claim submissions.  Participants will be encouraged to submit questions or provide feedback that may be incorporated into our supporting documents, such as the frequently asked questions document or the operational guide.

The CMS is committed to launching the DMEPOS Prior Authorization Program in an open and transparent manner that serves and protects patients as well as those who care for them.  CMS has the opportunity to learn from patient and provider/supplier experience and welcomes feedback as a critical part of this process.  We look forward to an ongoing dialogue to help us gather feedback and learn how the program can best meet patients’ needs.

Here is the link to our website where slides will be posted in advance of this ODF.  You will also find frequently asked questions, a fact sheet, and an operational guide in the downloads section.

The federal register notice announcing the six LLP items subject to prior authorization under this process can be found using this link.

We look forward to your participation.

Special Open Door Participation Instructions:

Participant Dial-In Number: 1-888-455-1397

Participant Passcode #: 6786274

Note: TTY Communications Relay Services are available for the Hearing Impaired. For TTY services dial 7-1-1 or 1-800-855-2880. A Relay Communications Assistant will help.

A transcript and audio recording of this Special ODF will be posted to the Special Open Door Forum website via this link  for downloading.

For automatic emails of Open Door Forum schedule updates (E-Mailing list subscriptions) and to view Frequently Asked Questions please visit our website.

Thank you for your interest in CMS Open Door Forums.