MAB2026062501

IMMEDIATE (Effective June 25, 2026): Billing team and providers must implement the following: (1) ALL upper extremity orthosis prescriptions now require prior authorization through PROMISe system - do not process claims without prior auth approval; (2) Update billing software and claim submission workflows to flag all upper extremity orthosis codes for mandatory prior authorization; (3) Create and distribute to ordering providers the required documentation checklist based on orthosis type: for shoulder orthoses (SO), elbow orthoses (EO), wrist-hand-finger orthoses (WHFO), and wrist-hand orthoses (WHO) - documentation requirements differ by type; (4) For initial requests: ensure medical diagnoses, imaging reports (X-Ray/MRI if appropriate), PT evaluation, functional status records, range of motion documentation, and documentation of previously tried/failed therapies are submitted; (5) For replacement requests: add documentation of existing orthoses condition, age, repair vs. replacement cost analysis, and alternatives considered; (6) Train front desk staff to verify prior authorization approval at check-in before providing services; (7) Implement denial management process for claims submitted without prior authorization approval - these will be denied by MA; (8) Reference the updated PROMISe Provider Handbook sections 7.1.2.19 (837 Professional/CMS-1500) and 7.1.2.17 (837 Institutional/UB-04) when submitting claims. Failure to obtain prior authorization will result in claim denials for all upper extremity orthosis services.