Preparing and submitting a DMEPOS prior authorization request

CMS asks for the beneficiary's name, Medicare number (MBI), date of birth, address, place of service, and diagnosis code; the supplier's name, NPI, PTAN, address, and phone; the requestor's contact details; and the HCPCS code(s). The coversheet also marks whether the request is initial, a resubmission, or expedited (with the reason), whether it includes an upgrade, and whether a beneficiary decision letter is requested. CGS's coversheet adds the treating practitioner's name and NPI.

Beyond identifiers, the request needs documentation from the medical record supporting medical necessity: the Standard Written Order, the face-to-face encounter note dated within six months before the order, and whatever the item's policy requires — for power mobility devices, Noridian lists the mobility evaluation, the specialty evaluation, and documentation of the RESNA-certified ATP's in-person involvement.

PARs can be sent by mail, fax, electronic submission of medical documentation (esMD, content type 8.4), or the MAC's portal — the Noridian Medicare Portal for Jurisdictions A and D, myCGS for B and C. Portal submissions need no coversheet; CGS calls its myCGS Prior Authorization Smart Submission the fastest route, and CMS encourages fax, esMD, or the portal for expedited requests to avoid mailing delays. Route by the beneficiary's permanent address.

Noridian's guidance: complete every field on the coversheet or portal form, send one request per fax transmission, do not submit duplicates to the same jurisdiction, and send legible copies. For ADR responses the same MAC asks for the letter on top of the packet, each claim faxed separately, and full one-sided sheets — habits worth applying to PARs too.

The MAC issues a decision within five business days (not to exceed seven calendar days) of receiving complete documentation, and resubmissions follow the same timeframe; expedited requests target two business days. Decision letters are sent by fax, mail, esMD, or portal to the supplier address on file with National Provider Enrollment, not the address written on the request.

The 14-byte UTN from the decision letter goes in the first 14 positions of Item 23 on the CMS-1500, or in the 2300 (or 2400) loop REF segment with qualifier G1 on electronic claims, and on each claim in a rental series. A claim for a required-PA item submitted without a UTN is automatically denied, typically with reason code 197 and remark N210. Affirmations are valid for a period that varies by program — from about a month for support surfaces to six months for mobility devices — so deliver inside the window.