On December 29, CMS published a final rule finalizing a prior authorization process for specific durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), which are frequently seen by the agency as utilized unnecessarily.

The final rule CMS put out says the authorization process will require the same information as is required to support Medicare payment. Where this requirement differs from the latter is in the submission timeline, which is earlier on in the process. The rule also brings a master list of DMEPOS items, which adhere to the criteria mentioned in the final rule. Only part of the list will at first come under the new requirements, while the rest will be carefully reviewed for the period mentioned in a 60-day notice in the Federal Register.

The requirement for prior authorization of medical articles includes submitting all relevant documentation before the item is handed over to the beneficiary, and before a claim is submitted for processing. The prior authorization claim will then undergo review by CMS or its contractors, who will subsequently provide a provisional affirmation or non-affirmation decision. If a claim is submitted along with a provisional affirmation decision, it will be paid in the event that all the other requirements under the final rule are met; otherwise, it will be denied. The rules also disallow unlimited resubmissions of prior authorization requests.

The master list provided as part of the final rule is a list of 135 DMEPOS items, which have been seen as subject to unnecessary utilization. These items will be on the provided list for 10 years, but can be removed sooner if the purchase amount for them drops below the payment threshold. After the 10-year period, items can be kept on the list or removed, and added back if another report sees it as once again subject to unnecessary utilization. An item being present on the master list does not cause the automatic creation of a prior authorization.

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