Prior authorization coversheet instructions
To submit a prior authorization request for hospital outpatient department services, complete the prior authorization request (PAR) cover sheet
Failure to populate every field listed below could result in delays in processing your request, a non-affirmed decision, or a determination that the request is incomplete and cannot be processed.
| Field | Description |
|---|---|
| Beneficiary last name | Enter the beneficiary’s full last name, to include Jr. or Sr. as appropriate. |
| Beneficiary first name | Enter the beneficiary’s full first name. |
| Medicare ID | Enter the beneficiary’s Medicare Beneficiary Identifier (MBI). |
| Date of birth | Enter the beneficiary’s date of birth (DOB) in MM/DD/YYYY format. |
| Facility NPI | Enter the hospital outpatient department's 10-digit National Provider Identifier (NPI). |
| Facility CCN/PTAN | Enter the hospital outpatient department's 6-digit CMS certification number (CCN). This is sometimes referred to as the Provider Transaction Access Number (PTAN). |
| Facility Fax number | Enter the hospital outpatient department's fax number. This will enable the HOPD to receive the prior authorization decision letter. |
| Facility name and address | Enter the hospital outpatient department's full name and street address, city, state, and ZIP code. |
| Physician NPI | Enter the performing physician's 10-digit NPI. |
| Physician PTAN | Enter the performing physician's 6-digit Medicare certification number (sometimes referred to as the PTAN). |
| Physician Fax Number | Enter the performing physician's fax number. This will enable the performing physician to receive a copy of the prior authorization decision letter. |
| Physician name and address | Enter the performing physician's full name and street address, city, state, and ZIP code. |
| Requestor name | Enter the full name of the individual submitting the prior authorization fax/mail coversheet and required medical records. |
| Requestor Email address | Enter the requestor's email address. |
| Requestor phone number | Enter the 10-digit telephone number (XXX-XXX-XXXX) of the individual who can be contacted for questions regarding the prior authorization fax/mail coversheet and medical records. |
| Alternative phone number and/or direct extension | Enter an alternate 10-digit telephone number (XXX-XXX-XXXX) or extension where we can reach to the requestor, if necessary. |
| Procedure code(s) | Enter the procedure code for the outpatient service requiring the PA. Refer to the CMS list of the specific Healthcare Common Procedure Coding System (HCPCS) codes that are included in the OPD PA program. |
| Modifier | Select the appropriate modifier either RT, LT or 50. |
| Site(s)/Level(s) | Enter the site/level, as applicable for the requested outpatient department services. |
| Units of Service | Enter the number of units being requested. |
| Request type | Select whether is an initial submission or a resubmission. |
| Diagnosis codes (esMD submission only) | Enter the diagnosis codes for the conditions necessitating the hospital outpatient department services. Providers who submit using esMD must include diagnosis code(s). |
| Anticipated date of service | Enter the date for the anticipated date of service. |
| State (location) of authorization | Enter the state based on where the hospital outpatient department is located. |
| Date submitted | Provide the date the coversheet was completed/submitted in MM/DD/YYYY format. |
| Comments | Please enter Previous Non-Affirm UTN for Resubmission requests, change in facility, record updates or reasons for expedited review. Any additional information applicable to assist with medical review. |
Note: Do not use the expedited prior authorization request coversheet unless the normal timeframe for a decision notification could jeopardize the life or health of the beneficiary. If the medical records submitted with the expedited request do not justify an expedited request, then the request will be subject to the normal process and timeframes.