CMS Issues Final Rule Creating DMEPOS Prior Authorization Process.

Date posted: December 31, 2015

The Centers for Medicare & Medicaid Services (CMS) recently released a final rule targeting unnecessary utilization of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items.  Medicare will only pay for DMEPOS items if a beneficiary’s medical record contains sufficient documentation of a medical condition that supports the type and quantity of items ordered.  The final rule establishes a prior authorization process to ensure that certain DMEPOS items are provided according to Medicare coverage, coding, and payment rules.  CMS aims to prevent the questionable use of DMEPOS items and safeguard beneficiary access to medically necessary care.

The final rule requires the same clinical documentation that is currently necessary to support Medicare payment.  However, the prior authorization process updates the payment process by:

  • Defining “unnecessary utilization” as the furnishing of items that do not comply with one or more of Medicare’s coverage, coding, and payment rules;
  • Adding a Master List of DMEPOS items potentially subject to prior authorization;
  • Requiring that claims for certain DMEPOS items have an associated “provisional affirmed” prior authorization decision as a condition of payment, or a preliminary finding that a future claim meets the Medicare payment rules;
  • Restricting the ability to appeal CMS Contractor decisions regarding prior authorization for DMEPOS items;
  • Establishing timeframes for review and approval of DMEPOS requests; and
  • Establishing an expedited process for review in cases where delays may jeopardize beneficiary health.

The final rule will take effect on February 29, 2016.

The final rule is available at:

https://www.gpo.gov/fdsys/pkg/FR-2015-12-30/pdf/2015-32506.pdf.

Medicare Program; Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies; Final Rule; 80 Fed. Reg. 81673, 81673-81707 (Dec. 30, 2015).

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