Before a hospital outpatient department in Kentucky or Ohio removes a panniculus for an Original Medicare patient, CGS needs this prior authorization request under CMS's OPD program. The attending surgeon's records must answer five questions on the reason for surgery, panniculus grade, conservative care or functional deficit, and weight stability after bariatric surgery. The decision's UTN goes on the hospital claim.
Hospital outpatient department staff complete the request with the OPD's PTAN, NPI and type of bill, the beneficiary, and the attending physician's name, NPI, fax and address, answering the clinical questions from the physician's documentation. CMS also lets a physician or practitioner submit on the hospital's behalf.
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Prior Authorization OPD: Panniculectomy
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Q5 asks whether the procedure follows significant weight loss as a result of bariatric surgery, whether the weight has been stable for 6 months, and whether the beneficiary is at least 18 months after surgery. A No answer means the procedure may not be considered medically necessary.
Claims for associated anesthesia, physician and facility services in the outpatient setting may automatically deny, or deny after payment, when the primary OPD service is non-affirmed or its claim is denied. The hospital can resubmit a corrected request as often as needed before billing.
Ohio ambulatory surgical centers use PAR 804 under CMS's ASC prior authorization demonstration, while PAR 254 is for hospital outpatient departments in Kentucky and Ohio under the nationwide OPD program. The clinical questions on both forms match; the facility fields and claim rules differ.