Retroactive Medicare drug authorizations ending Jan. 1, 2019

Today, when a participating provider submits a retrospective payment dispute, the pharmacy department will process a retroactive authorization request. This occurs when Medicare Part B (medical injectable) medications are administered without prior approval. This process has been followed as a courtesy and is not a requirement of CMS.

Effective Jan. 1, 2019 retroactive authorizations will no longer be processed for Medicare Part B (medical injectable) medications that require prior approval.  Specifically, providers need to request a Pre-Service Organization Determination (PSOD) before administering the drug. If a PSOD is not obtained and claims are rejecting for provider liability, the provider payment dispute process should be followed moving forward.

How to know which drugs need a pre-service organization determination

Drug prior authorization forms and the PSOD process overview are located on the website.  Currently, there is information in both the logged-in provider center and out-of-network guide for providers who don’t have an account on Find drug-specific authorization forms or request a PSOD. 

What if a pre-service organization determination was not obtained prior to administering the Medicare Part B medication?

Once a service has been performed, the service is considered a request for payment so a provider needs to submit the claim as is.  A provider can choose to file a dispute to the claim determination once it’s processed if they’re unsatisfied with the outcome.  

Evidence of Coverage

The Evidence of Coverage is the legal, detailed description of benefits and costs for the plan year. It also explains the rights and rules providers will need to follow when using coverage for medical care and prescription drugs.  Find links to each Medicare plan’s EOCs.

What if a drug is not covered?

If a drug is clearly non-covered or excluded from the Member's Evidence of Coverage, a Pre-Service Organization Determination may be needed. The Centers for Medicare and Medicaid Services (CMS) rules require that all Part C (Medicare Advantage) plans - NOT providers - give a specific written notice to members if a service or item isn't covered. The process for getting this written notice of non-coverage from Priority Health is called requesting a PSOD.  The PSOD process replaced the Advanced beneficiary Notice (ABN) form that now only Original Medicare members are allowed to use.

The PSOD process differs from the rule for fee-for-service Medicare ("Original Medicare") patients, which allows you, the provider, to give written notice. The Part C rule can be found in the Medicare Managed Care Manual, Section 160, Chapter 4, Benefits and Beneficiary Protections. It applies to all Part C Medicare Advantage plans.

Whether or not the member requests a PSOD, the member can't be held financially responsible for a non-covered service unless there's a clear exclusion in the member's Evidence of Coverage (EOC) plan document, or Priority Health issues a Notice of Denial of Medicare Coverage.