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CMS Announces New ASC Prior Authorization Demonstration

Published on 

Wednesday, April 3, 2024

Did You Know?

In mid-February CMS announced a new Prior Authorization Demonstration for certain Ambulatory Surgical Center (ASC) Services.


Why It Matters?

In their announcement, CMS references the nationwide prior authorization process for certain hospital outpatient department (OPD) services that was finalized in the Calendar Year 2020 OPPS Final Rule and implemented on July 1, 2020. The initial services subject to prior authorization in 2020 were blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty, and vein ablation procedures.


This 5-year demonstration project design will include ASC providers that:

  • Submit claims with place of service 24 (Ambulatory Surgical Center) for one of the five previously mentioned services,
  • Are in one of the ten demonstration states (California, Florida, Texas, Arizona, Ohio, Tennessee, Pennsylvania, Maryland, Georgia, and New York), and
  • Submit claims to Medicare fee-for-service.


CMS plans to implement this demonstration for all ten states in one phase and they do not anticipate beginning the demonstration earlier than the fall of 2024.


Why now? CMS indicates that data from 2019 to 2021 shows there has been a significant increase in utilization in the ASC for the above five services and they were selected “for inclusion in this demonstration, based upon problematic events, data, trends, and potential billing behavior impacts of the OPD Prior Authorization Program which requires prior authorization as a condition of payment for these services.”


What Can You Do?

Take the time to read CMS Form CMS-10884 to learn about details of the demonstration design and justification for the need for this demonstration.


Since “the documentation requirements that MACs already have for the services in the OPD program, including local coverage determinations (LCDs), are applicable to these ASC services as well” visit your MACs website to find related resources. For example, Palmetto GBA Jurisdiction J (JJ), the MAC for Tennessee and Georgia has several resources available on their Medical Review / Outpatient Prior Department Prior Authorization (PA) webpage (i.e., Blepharoplasty and Medical Necessity Module).


Finally, if you are in one of the demonstration states, share this information with key stakeholders at your facility.

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.