Glossary / Prior authorization
Prior authorization Medicare DME termPrior authorization
Medicare's pre-delivery review for listed DMEPOS items; the DME MAC issues a provisional affirmation or non-affirmation before you deliver and bill.
Prior authorization (PA) is a process in which the supplier sends the documentation for a DMEPOS item to the DME MAC before delivering it, and the MAC says in advance whether a future claim would meet Medicare's coverage, coding, and payment rules. Under 42 CFR 414.234 it is a condition of payment only for items on CMS's Required Prior Authorization List, which is drawn from a broader Master List.
The Required List currently covers six categories: power mobility devices, certain manual wheelchair bases, lower limb prostheses, spinal and knee orthoses, pressure reducing support surfaces, and pneumatic compression devices. A claim for a listed item that never received a PA decision is denied. Most other DME, including CPAP, oxygen, and hospital beds, has no PA step and is checked after billing through prepayment review and ADRs.
The DME MAC issues a decision within 5 business days (not to exceed 7 calendar days) of receiving complete documentation, or within 2 business days when expedited review is warranted. An affirmation comes with a Unique Tracking Number (UTN) that goes on the claim. A non-affirmation can be revised and resubmitted an unlimited number of times.
Common questions
Does every DME item need prior authorization?
No. Only items on the Required Prior Authorization List. Everything else is judged against the same documentation rules after submission, which is why the checklist matters even when there is no PA decision to wait for.
Who submits the PA request, and how?
The supplier usually does, through the MAC portal, esMD, fax, or mail. The request includes the Standard Written Order, the face-to-face and clinical records, and any item-specific evidence the LCD requires.
Does software submit the PA request for me?
No. AffirmDME builds the per-item readiness checklist and flags missing documents before you submit; the submission itself goes through your MAC's channels.
Related
- Affirmation and non-affirmation
- UTN
- Medicare DMEPOS prior authorization list
- PA vs ADR vs prepayment review
See the term in a real checklist.
AffirmDME's readiness checklist names each requirement with its citation, so the vocabulary on this page is what you see on a case. Free to explore in sandbox mode.
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Sources: 42 CFR 414.234 — Prior authorization for certain DMEPOS items · CMS: Prior Authorization Process for Certain DMEPOS Items · CMS: DMEPOS Prior Authorization Operational Guide · Noridian JA DME: Required Prior Authorization Programs . Definitions summarize public Medicare policy and are not legal or billing advice.
More terms
- ADR — Additional Documentation Request
- Affirmation and non-affirmation
- UTN — Unique Tracking Number
- SWO — Standard Written Order
- Face-to-face encounter
- DME MAC — Durable Medical Equipment Medicare Administrative Contractor
- Jurisdiction
- PTAN — Provider Transaction Access Number
- NPI — National Provider Identifier
- MBI — Medicare Beneficiary Identifier
- LCD — Local Coverage Determination
- NCD — National Coverage Determination
- Policy article
- HCPCS — Healthcare Common Procedure Coding System
- Length of need
- Prior authorization exemption
- Competitive bidding
- CMN and DIF — Certificate of Medical Necessity and DME Information Form
- Proof of delivery
- TPE — Targeted Probe and Educate
- Prepayment review