(Medicare Program Integrity Manual)

The CMS may elect to exempt a provider from this prior authorization process upon a providers demonstration of compliance with Medicare coverage, coding, and payment rules after semiannual assessments.  Providers must reach a prior authorization provisional affirmation threshold of 90 percent or greater to be eligible for exemption.  The CMS may suspend the outpatient department services prior authorization process requirements generally or for a particular service(s) at any time by issuing notification on the CMS website.                                       Transmittals Issued for this Chapter   Rev #  Issue Date  Subject  Impl Date  CR#  R12056PI  05/25/2023  Update to Chapt er 3 of Publication (Pub.) 100-08 (Program Integrity Manual (PIM)) for the Voluntary Prior Authorization (PA) Process for Durable Medical Equipment, Prosthetics, Orthotics, Supplies (DMEPOS) Accessories   06/26/2023  13185  R11933PI  03/30/2023  Update to Process and Responsibility for Tracking Medicare Contractors' Prepayment and Post Payment Reviews in the RAC Data Warehouse (RACDW)  04/03/2023  12281  R11697PI  11/09/2022  Update to Process and Responsibility for Tracking Medicare Contractors' Prepayment and Post Payment Reviews in the RAC Data Warehouse (RACDW) - Rescinded and Replaced by Transmittal 11933  04/03/2023  12881 R11529PI  07/28/2022  Update of Chapter 3 in Publication (Pub.) 100-08, Including Update to Medicare Program Integrity Contractor Post- Payment Review Process, and Update of Chapter 8 Pub. 100-08, Including Revision to When Contractor Suspects Additional Improper Claims  08/30/2022  12827  R11032PI  09/30/2021  Updates to Chapters 1, 3, 4, 5, 8 and 9 of Publication (Pub.) 100-08 11/10/2021  12375  R10984PI  09/09/2021  Updates to Chapters 1, 3, 4, 5, 8 and 9 of Publication (Pub.) 100-08 - Rescinded and Replaced by Transmittal 11032  11/10/2021  12375  R10365PI  10/02/2020  Updates to Chapters 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, and Exhibits of Publication (Pub.) 100-08  08/27/2020  11884  R10228PI  07/27/2020  Updates to Chapters 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, and Exhibits of Publication (Pub.) 100- 08 Rescinded and Replaced by Transmittal #10365  08/27/2020  11884  R10197PI  06/26/2020  Publication (Pub.) 100 -08 Chapter 3 Updates to Section 3.2.3.2 (Timeframes for Submission) and Section 3.2.3.8 (No Response or Insufficient Response to Additional Documentation Requests 07/27/2020  11730  Rev #  Issue Date  Subject  Impl Date  CR#  (ADRs))  R10190PI  06/19/2020  Revising Chapters 3 and 5 of Publication (Pub.) 100- 08, to Reflect the Recent Final Rule CMS -1713 -F 07/01/2020  11599  R10171PI  06/12/2020  Updates to Durable Medical Equipment, Prosthetics, Orthotics & Supplies (DMEPOS) and Ambulance Certification Signature Requirements  07/13/2020  11763  R10132PI  05/15/2020  Revising Subsection 3.2.5, Targeted Probe and Educate (TPE), in Chapter 3 of Publication (Pub.) 100 -08 06/16/2020  11695  R10100PI  05/08/2020  Revision to Language in Chapter 3, Section 3.7.5 (Corrective Action Reporting Requirements) of Publication (Pub.) 100 -08 06/09/2020  11756  R937PI  01/31/2020  Updates to the Prior Authorization (PA) Guidance Within Publication (Pub.) 100-08  03/02/2020  11633  R933PI  01/10/2020  Update to Chapter 3, Section 3.2.3.1 Additional Documentation Requests (ADR) of Publication (Pub) 100-08  01/06/2020  10828  R912PI  10/18/2019  Medicare Administrative Contractor (MAC) Verification of Potential Errors and Corrective Actions Ta ken 11/19/2019  11463  R907PI  10/04/2019  Update to Chapter 3, Section 3.2.3.1 Additional Documentation Requests (ADR) of Publication (Pub) 100-08- Rescinded and Replaced by Transmittal #933  01/06/2020  10828  R902PI  09/27/2019  Updates to Chapters 3, 4, 8, 15, and Exhibits of Publication (Pub.) 100 -08 10/28/2019  11425  R876PI  04/12/2019  Update to Publication (Pub.) 100 -08 to Provide Language-Only Changes for the New Medicare Card Project  05/13/2019  11109  R853PI  01/04/2019  Updates to the Appeals Prioritization Process  02/05/2019  10641  R833PI  10/12/2018  Templates in Medical Review  11/13/2018  10930  R825PI  09/21/2018  Credentials of Reviewers (This Change Request (CR) Rescinds and Fully Replaces CR 10157.)  10/22/201 8 10909  R819PI  08/17/2018  Adding a Targeted Probe and Educate (TPE) Sub-Section Into Section 3.2 of Chapter 3 in 09/17/2018  10876  Rev #  Issue Date  Subject  Impl Date  CR#  Publication (Pub.) 100 -08 R796PI  05/11/2018  Intent to Reopen  08/13/2018  9855  R802PI