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PRIOR AUTHORIZATIONS

On December 29, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a rule finalizing a prior authorization process for certain durable medical equipment, prosthetics, orthotics and supplies (DMEPOS).  The final rule implements Section 1834(a)(15) of the Social Security Act, which authorizes the Secretary of the Department of Health and Human Services (HHS) to develop and periodically update a list of DMEPOS that the Secretary determines to be “frequently subject to unnecessary utilization” and to develop a prior authorization process for these items.  CMS had issued a proposed rule on this issue on May 28, 2014.  The final rule largely (but not totally) reflects the provisions of the proposed rule.

CMS finalized a two-step process for identifying items subject to prior authorization, including; (1) developing a Master List of DMEPOS items that are “frequently subject to unnecessary utilization,” and (2) selecting a subset of items on the Master List for the Required Prior Authorization List, which will be subject to prior authorization.  In addition CMS finalized general requirements related to the prior authorization process.  CMS intends to issue specific prior authorization guidance in future subregulatory communications.

No infusion or parenteral or enteral nutrition products are included in the final Master List of DMEPOS items subject to frequent unnecessary utilization for prior authorizationAs a result, these products will not be subject to prior authorization under this final rule at the present time.

Click here to access the final rule text.

For a summary of the rule provided by NHIA’s counsel, Alan Parver, at the firm Arnall Golden Gregory LLC, click here.