In CY 2020, CMS established a nationwide prior authorization process and requirements for certain outpatient department (OPD) services. Providers must submit a prior authorization request to the Medicare Administrative Contractor (MAC) for services included on the list of OPD services that require ...
CMS is also requiring impacted payers to maintain an attribution process to associate patients with in-network or enrolled providers with whom they have a treatment relationship and to allow patients to opt out of having their data available to providers under these requirements. Impacted payers will...
1 Broadly, the CMS criteria require beneficiaries to have multiple chronic conditions selected from a list of qualifying conditions, use specific medications covered by Medicare Part D, and meet a specified total estimated annual medication cost covered by Medicare Part D.1 Sponsors, which are the ...
The person receives services from a provider who has elected to opt-out of Medicare. Medicare benefits are determined as if the services were covered under Medicare Parts A and B and the provider had agreed to limit charges to the amount of charges allowed under Medicare...