prior auth
Rick Carson
Description
Collection
Title:
prior auth
Creator:
Rick Carson
Date:
7/22/2014
Text:
I have been reading all the posts regarding prior auth. I would like to
offer a different take on this issue. I believe it was 20 something
years ago, the feds had written into the social security act a law
pertaining to customized DME items that were not of an inexpensive
nature of which prosthetic limbs would definitely qualify. The law
states that either a supplier or a patient can request an Advanced
Determination of Medicare Coverage before providing services. This is
the same law that CMS uses now for Power Mobility Devices. I have
searched and searched for any addendums or qualifying statements to this
law and have not found any. Here is a copy of the exact wording from
the Social Security Act.
5.16 – Advance Determination of Medicare Coverage (ADMC) of Customized
DME
(Rev. 167, Issued: 10-27-06; Effective: 10-01-06; Implementation:
10-02-06)
Section 1834(a)(15)(C) of the Act provides that carriers shall, at the
request of a supplier or beneficiary, determine in advance of delivery
of an item whether payment for the item may not be made because the item
is not covered if:
• The item is a customized item,
• The patient to whom the item is to be furnished, or the supplier,
requests that such advance determination be made, and
• The item is not an inexpensive item as specified by the Secretary.
This section provides for direction in implementing §1834 (a)(15)(C) of
the Act.
It is important to note that ADMCs are not initial determinations as
defined at 42 CFR 405.801(a), because no request for payment is being
made. As such, an ADMC cannot be appealed.
This is a voluntary program. Beneficiaries and suppliers are not
required to submit ADMC requests in order to submit claims for items.
Additionally, DME PSCs may not require an ADMC request as a prerequisite
for submitting a claim.
5.16.1 – Items Eligible for ADMCs
(Rev. 242: Issued: 02-22-08; Effective/Implementation Dates: 03-01-08)
The DME MACs shall publish examples of the types of items for which
ADMCs are available. These examples shall be published yearly in the DME
MAC’s Supplier Manual or yearly in the DME MAC’s Supplier Bulletin.
Examples will be published in the form of HCPCS codes eligible for this
program. Because HCPCS codes describe general “categories of equipment,
this list is not a list of specific items, but rather a general list of
the categories of types of items eligible for this program.
Prosthetic Limbs should definitely qualify for these ADMC's. The key
bullet in this law is number 3. It is up to the Secretary of HHS to
come up with a list of items that qualify for ADMC's.
After all these years, the only items on this list are PMD's. It seems
to me that it would make a lot more sense to force the DMAC's to adhere
to a law that is already on the books rather than create a completely
new program. I just spoke with Senator Susan Collins' office this
morning to have her investigate why CMS has never mandated the DMAC's to
follow this law and I encourage everyone who is interested to do the
same. Contact your Senators as well as CMS and voice your concern. The
advantage of this proposal is that ADMC's are voluntary as opposed to
prior auth's which will be mandatory.
Rick Carson
Patient Care Coordinator
********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>
OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
offer a different take on this issue. I believe it was 20 something
years ago, the feds had written into the social security act a law
pertaining to customized DME items that were not of an inexpensive
nature of which prosthetic limbs would definitely qualify. The law
states that either a supplier or a patient can request an Advanced
Determination of Medicare Coverage before providing services. This is
the same law that CMS uses now for Power Mobility Devices. I have
searched and searched for any addendums or qualifying statements to this
law and have not found any. Here is a copy of the exact wording from
the Social Security Act.
5.16 – Advance Determination of Medicare Coverage (ADMC) of Customized
DME
(Rev. 167, Issued: 10-27-06; Effective: 10-01-06; Implementation:
10-02-06)
Section 1834(a)(15)(C) of the Act provides that carriers shall, at the
request of a supplier or beneficiary, determine in advance of delivery
of an item whether payment for the item may not be made because the item
is not covered if:
• The item is a customized item,
• The patient to whom the item is to be furnished, or the supplier,
requests that such advance determination be made, and
• The item is not an inexpensive item as specified by the Secretary.
This section provides for direction in implementing §1834 (a)(15)(C) of
the Act.
It is important to note that ADMCs are not initial determinations as
defined at 42 CFR 405.801(a), because no request for payment is being
made. As such, an ADMC cannot be appealed.
This is a voluntary program. Beneficiaries and suppliers are not
required to submit ADMC requests in order to submit claims for items.
Additionally, DME PSCs may not require an ADMC request as a prerequisite
for submitting a claim.
5.16.1 – Items Eligible for ADMCs
(Rev. 242: Issued: 02-22-08; Effective/Implementation Dates: 03-01-08)
The DME MACs shall publish examples of the types of items for which
ADMCs are available. These examples shall be published yearly in the DME
MAC’s Supplier Manual or yearly in the DME MAC’s Supplier Bulletin.
Examples will be published in the form of HCPCS codes eligible for this
program. Because HCPCS codes describe general “categories of equipment,
this list is not a list of specific items, but rather a general list of
the categories of types of items eligible for this program.
Prosthetic Limbs should definitely qualify for these ADMC's. The key
bullet in this law is number 3. It is up to the Secretary of HHS to
come up with a list of items that qualify for ADMC's.
After all these years, the only items on this list are PMD's. It seems
to me that it would make a lot more sense to force the DMAC's to adhere
to a law that is already on the books rather than create a completely
new program. I just spoke with Senator Susan Collins' office this
morning to have her investigate why CMS has never mandated the DMAC's to
follow this law and I encourage everyone who is interested to do the
same. Contact your Senators as well as CMS and voice your concern. The
advantage of this proposal is that ADMC's are voluntary as opposed to
prior auth's which will be mandatory.
Rick Carson
Patient Care Coordinator
********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>
OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
Citation
Rick Carson, “prior auth,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/236562.
