CMS Pub. 100-08, ch. 3, § 3.10

The term Medicare beneficiary identifier (Mbi) is a general term describing a

beneficiary's Medicare identification number. For purposes of this manual, Medicare

beneficiary identifier references both the Health Insurance Claim Number (HICN) and

the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition

period and after for certain business areas that will continue to use the HICN as part of

their processes.

A. Overview

Prior authorization is a process through which a request for provisional affirmation of

coverage is submitted to CMS or its contractors for review before the item or service is

furnished to the beneficiary and before the claim is submitted for processing. It is a

process that permits the submitter (e.g., provider, supplier, beneficiary, etc.) to send in

medical documentation in advance of providing and billing for an item or service, to

verify its eligibility for Medicare claim payment. Contractors shall, at the direction of

CMS or other authorizing entity, conduct prior authorizations and alert the submitter of

any potential issues with the information, as submitted.

For any item or service to be covered by Medicare it must:

• Be eligible for a defined Medicare benefit category,

• Be medically reasonable and necessary for the diagnosis or treatment of illness or

injury or to improve the functioning of a malformed body member, and

• Meet all other applicable Medicare coverage, coding and payment requirements.

Contractors shall communicate to the submitter (and beneficiary upon request) their prior

authorization decision and the assigned unique tracking number (UTN), which indicates

that the submitter requested a prior authorization, for corresponding claim submissions.

For certain prior authorization programs, the requirement to prior authorize is a condition

of payment, as further described in the sections below.

Absent any explicit CMS instruction to the contrary, submitters may correct identified

issues with their prior authorization request(s) and resubmit their request(s) for prior

authorization without restriction. Contractors shall conduct prior authorization reviews

within the timeframes defined by CMS in the corresponding prior authorization program

operational instruction(s).

The prior authorization process is further described in following sections.

B. Condition of Payment

Contractors shall determine if the requirement to prior authorize a particular item or

service is a condition of payment, as specified in the individual operational instruction(s).

If prior authorization is a condition of payment, claims submitted without an indication

that the submitter made a prior authorization request (i.e., UTN) shall be denied upon

receipt.

C. Outreach and Education

Contractors shall educate stakeholders each time a new prior authorization program is

launched for a particular item or service, the requisite information and timeframes for

prior authorization submissions, and the vehicle(s) for submitting such information to the

contractor for assessment. Contractors shall make sure submitters are aware of the

timeframes for contractors to render prior authorization decisions, for each individual

prior authorization program.

Each prior authorization program will have an associated Operational Guide and will be

available on the CMS website. Contractors shall, at a minimum, provide public access to

agency-developed prior authorization operational guides, by posting the link(s) on their

website.

Contractors shall hold group or individualized training sessions, as appropriate, to notify

the stakeholders of upcoming prior authorization programs and to make sure there is

ongoing understanding of the specific requirements for those applicable prior

authorization programs.

D. Prior Authorization Submission

Contractors shall assess the information/documentation included in the prior

authorization submission for completeness. Requisite information for individualized

prior authorization programs will be included in the operational guides, and shall be

available on the CMS website.

Requisite information may include, but is not limited to:

• Beneficiary Information (i.e., name, Medicare beneficiary identifier, date of birth)

• Physician/Practitioner Information (i.e., name, provider identification number,

address)

• Supplier Information (i.e., name, national supplier clearinghouse (NSC) number,

identification number, address)

• Documentation from the medical record to support the medical necessity of the

item or service, and

• Any other relevant documents as deemed necessary by the contractor to process

the prior authorization.

E. Prior Authorization Decisions

Contractors shall notify the submitter if their prior authorization submission results in a

provisional affirmative, or non-affirmative decision.

• A provisional affirmative decision is a preliminary finding that a future claim

submitted to Medicare for the item or service likely meets Medicare’s coverage,

coding, and payment requirements.

• A non-affirmative decision is a finding that the submitted

information/documentation does not meet Medicare’s coverage, coding, and

payment requirements, and if a claim associated with the prior authorization is

submitted for payment, it would not be paid. Contractors shall provide

notification of the reason(s) for the non-affirmation, if a request is non-affirmative, to the submitter. If a prior authorization request receives a non-affirmative decision, the prior authorization request can be resubmitted an

unlimited number of times, unless otherwise specified.

Contractors shall send detailed decision letters to submitters. As appropriate for the

given prior authorization program, contractors shall send detailed decision letters to other

stakeholders (e.g., beneficiaries) using their official address on file. In addition, there

may be certain prior authorization programs that require the contractors to notify the

appropriate entity by other means, such as telephone.

If a claim is submitted for payment without an affirmative prior authorization decision on

file, contractors shall use their existing processes to either suspend claims for additional

review or to process claims as denials, based on each individualized prior authorization

program, as detailed in the operational instruction.

F. Expedited Request

For certain items or services, delays in receipt of a prior authorization decision could

jeopardize the life or health of the beneficiary. Contractors shall, for such items or

services, expedite their decisions based on the operational instruction.

If the claim processing systems would unavoidably delay the delivery of the UTN in an

expedited fashion, contractors shall nonetheless render an affirmative or non-affirmative

decision to the submitter within the mandated, expedited timeframe. Contractors shall

alert the submitter that the decision is being provided as expediently as possible, so that

the item or service may be provided, but that the submitter should hold their claim and

not submit it until such time as the UTN is received (in order to avoid a claims payment

denial).