Prior Authorization Requirements CMS

What is Prior Authorization?

Prior authorization (PA) is payer review of a planned service before delivery to confirm medical necessity and coverage. CMS mandates PA for specific Medicare services including DMEPOS items, certain surgeries, and specialized treatments. PA must be obtained before service delivery. Claims submitted without PA approval are automatically denied even if the service meets all other billing requirements.

Who Does Prior Authorization Affect?

Orthopedic surgeons, therapy clinics, DME suppliers, and hospitals with high surgical volume face extensive PA requirements. A typical orthopedic practice manages 200-300 PA requests monthly. DME suppliers cannot deliver items without PA approval. Hospitals report PA delays postponing surgeries by 5-7 days on average. The American Medical Association reports 92% of providers say PA requirements delay patient care.

Key Requirements

  1. PA must be obtained before service delivery. Retroactive PA denials cannot be appealed; claims are denied without recourse.
  2. CMS-0057-F mandates response timeframes: 72 hours for urgent requests, 15 days for standard requests. Payer failure to respond within these windows results in deemed approval.
  3. PA requests must include clinical documentation: diagnostic test results, clinical notes justifying the service, and physician recommendation. Incomplete submissions may be rejected.
  4. Authorization numbers must be documented on all claim submissions referencing the PA. Missing authorization numbers prevent claim matching to PA approval.
  5. PA approvals are service-specific and time-limited. A PA for 30 physical therapy visits does not authorize additional visits after the limit.

Timeline & Enforcement

Medicare contractors enforce PA compliance through prepayment review. Services without PA approval are automatically denied on the claim. PAC (Prior Authorization Committee) audits track provider compliance quarterly. Providers with high rates of missing PA receive notice of compliance review. Overpayment recovery for claims billed without PA averages $15,000-$40,000 annually for high-volume practices. Some contractors impose monthly claim hold percentages for providers with poor PA compliance.

How to Comply

  1. Maintain an internal PA requirement checklist for all services your practice provides. Update the list quarterly when payer policies change.
  2. Build PA requests into your workflow before patient scheduling. Require PA approval before authorizing appointments.
  3. Submit PA requests with complete clinical documentation within 5 business days of diagnosis. Track request submission and response dates.
  4. Document all authorization numbers in the patient record and claim submission. Use a consistent format so billing staff can verify approval on all claims.
  5. Appeal denied PA requests within 30 days. Resubmit with additional clinical evidence if the first request was incomplete.

Common Questions

Which services require prior authorization?

DMEPOS items, orthopedic surgeries, certain physical therapy episodes, inpatient hospital stays exceeding 3 days, specialized imaging, and multiple drug regimens. Check with your specific Medicare contractor for jurisdiction-specific PA requirements.

What is the CMS-0057-F requirement?

CMS-0057-F mandates payers respond to urgent PA requests within 72 hours. Non-urgent requests have 15 days. Failure to respond within the timeframe results in deemed approval of the PA request.

What happens if you bill without PA approval?

Claims billed without required PA are denied under CO-50 or CO-197. Recoupment is mandatory. Appeals fail because the claim violates payer policy, not coding or medical necessity rules.

Related Resources

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CMS regulations change. This reference is current as of 2026-03-30. Always verify against current CMS documentation.