Medicare Program; Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
medicare · Centers for Medicare and Medicaid Services · Rule · Published 2015-12-30 · Effective 2016-02-29 · 80 FR 81674
Document
Document number
2015-32506
Federal Register citation
80 FR 81674
CFR reference
42 CFR 405
Type
Rule
Action
Final rule.
Category
medicare
Sub-agency
Centers for Medicare and Medicaid Services
Publication date
2015-12-30
Effective date
2016-02-29
HHS docket
CMS-6050-F
Abstract
This final rule establishes a prior authorization program for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items that are frequently subject to unnecessary utilization. This rule defines unnecessary utilization and creates a new requirement that claims for certain DMEPOS items must have an associated provisional affirmed prior authorization decision as a condition of payment. This rule also adds the review contractor's decision regarding prior authorization of coverage of DMEPOS items to the list of actions that are not initial determinations and therefore not appealable.