Non-Affirmed Code Crosswalk: Prior Authorization Request

Code

Description

PAR 1

The documentation received did not contain the necessary PCS (Physician Certification Statement). (Per 42 C.F.R. § 410.40(d)(2)(i))

PAR 2

The documentation received did not indicate the origin and/or destination of the transports. (Per 42 C.F.R. § 410.40(e))

PAR 3

The PCS (Physician Certification Statement) received is missing a physician signature with credentials or is illegible.  (Per 42 C.F.R. § 410.40(d)(2)(i))

PAR 4

The PCS (Physician Certification Statement) received is not dated OR the date is pre-filled. (Per 42 C.F.R. § 410.40(d)(2)(i))

PAR 5

The Referring Physician name on the Prior Auth Request Form must match the Certifying Physician on the Physician Certification Statement (PCS).  (Per 42 C.F.R. § 410.40(d)(2)(i))

PAR 6

The PCS (Physician Certification Statement) received does not indicate why transportation by any other means is contraindicated. (Per 42 C.F.R. § 410.40(d)(1))

PAR 7

The physician’s signature on the PCS (Physician Certification Statement) was obtained after the date requested as the ‘Start of the 60 Day Period’ on the Prior Authorization request form.  This signature must be obtained prior to the transport for scheduled, repetitive transports. (Per 42 C.F.R § 410.40(d)(2)(i))

PAR 8

The physician’s signature on the PCS (Physician Certification Statement) is greater than 60 days prior to the start of the 60 day period provided on the Prior Authorization Request Form.  The PCS is only valid for a period of 60 days. (Per 42 C.F.R. § 410.40(d)(2)(i))

PAR 9

The ‘Request Type’ section on the Prior Authorization Request form was incomplete.
  • Initial
  • Resubmission
  • Expedited. If this type is indicated, you must provide the ‘reason’ the request should be expedited.
  • Number of transports requested

PAR 10

The ‘Ambulance Supplier/Provider Information’ section on the Prior Authorization Request form was incomplete.

  • Provider name
  • NPI
  • PTAN
  • Address
  • State where the ambulance is garaged

PAR 11

The ‘Beneficiary Information’ section on the Prior Authorization Request form was incomplete.

  • First Name
  • Last Name
  • Health Insurance Number
  • Date of Birth
  • Gender

PAR 12

The ‘Claim Information’ section on the Prior Authorization Request form was incomplete.

  • Start of 60 Day Period
  • Procedure Code
  • Modifier
  • Certifying Physician Name
  • NPI
  • Address
  • City, State, Zip

PAR 13

The ‘Requestor Information’ section on the Prior Authorization Request form was incomplete.

  • Name
  • Phone Number
  • Signature
  • Date
PAR 14  The documentation submitted does not support that transport services were medically necessary.  The documentation supports that alternative services could have been used. (Per 42 C.F.R. § 410.40 (d))

Action Code: P14, Requires ABN: false
 PAR 14 A No supporting medical documentation (i.e. history and physical, wound care notes, progress notes, etc.) was received with this submission.  

PA14A: No supporting medical documentation (i.e. history and physical, wound care notes, progress notes, etc.) was received with this submission.
Action Code: 14a, Requires ABN: false
 PAR 14 B 

The documentation submitted does not provide an indication of patient status and needs at time of transport period.

PA14B: The documentation submitted does not provide an indication of patient status and needs at time of transport period.
Action Code: 14b, Requires ABN: false  

PAR 14 C 

The supporting documentation is not legible.

PA14C: The supporting documentation is not legible.
Action Code: 14c, Requires ABN: false 

PAR 14 D 

The documentation does not indicate bed-confined status or inability to transfer by other means.

PA14D: The documentation does not indicate bed-confined status or inability to transfer by other means.

Action Code: 14d, Requires ABN: false  

PAR 14 E  The documentation submitted is not for the patient indicated on the PA form and PCS.

PA14E: The documentation submitted is not for the patient indicated on the PA form and PCS.
Action Code: 14e, Requires ABN: false  
PAR 15 The documentation received does not support expedited requests.

Contact Palmetto GBA JM Part B Medicare

Email Part B

Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

Other Palmetto GBA Sites

Palmetto GBA Home

DMEPOS Competitive Bidding Program

Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC

MolDX

National Supplier Clearinghouse MAC

PDAC

RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries

Anonymous

 

Click to Chat Now