Prior Authorization, Prior Approval, and Predetermination of Benefits Requests CBT Script
WPS Medicare often receives requests for prior authorization, prior approval, or a predetermination of benefits. Unfortunately, while a proposed treatment plan could offer insight into a patient's condition, the actual service and follow-up care provided may differ based on the patient's condition at the time the service is rendered. For this reason, the Original Medicare program does not give prior authorization, prior approval, or a predetermination of benefits for any service.
You can find general coverage guidelines for many services using the Medicare Coverage Database (MCD). This searchable database, maintained by the Centers for Medicare & Medicaid Services (CMS), is located on the CMS Website at the following address:
http://www.cms.hhs.gov/mcd/overview.asp 
Providers can also find WPS Medicare's coverage and billing guidelines for many services using our Local Coverage Determinations (LCDs). You can locate our policies on our Website at the following address: http://www.wpsmedicare.com/part_b/policy/policy_active.shtml
In the absence of a local or national coverage policy, WPS Medicare determines whether coverage is available for a service on a case-by-case basis using the documentation submitted with the claim for payment. WPS Medicare may also request additional medical documentation at the time the claim is processed. Section 1862(a)(1)(A) of the Social Security Act states that Medicare may not provide payment for items and services unless they are "reasonable and necessary" for the treatment of illness and injury.
Page Last Updated: Thursday, 18-Mar-2010 05:56:59 CDT
