MAB2026072001

Effective July 20, 2026: Billing team must implement prior authorization requirements for ALL upper extremity prosthetic prescriptions and components for PA Medical Assistance Fee-for-Service patients. SPECIFIC ACTIONS: (1) Update billing system to flag upper extremity prosthetic orders requiring prior authorization before claims are submitted; (2) Create internal checklist requiring submission of: medical diagnoses, specialist clinical evaluation (physiatrist or equivalent), prosthetist clinical assessment with medical justification for each component, functional goals documentation, and pre-prosthetic training records; (3) For replacement prosthetics, require documentation of reason for replacement, previous use outcomes, beneficiary motivation, and estimated length of need; (4) Train front desk and clinical staff to communicate prior authorization requirements to prescribers; (5) Update encounter forms and order templates to prompt providers for required clinical documentation; (6) Direct providers to reference PROMISe Provider Handbook Sections 7.1.2.17 (Professional/CMS-1500) or 7.1.2.15 (Institutional/UB-04) for detailed requirements. RESPONSIBILITY: Billing team coordinates with clinical staff and providers. CONSEQUENCE: Claims submitted without required prior authorization and supporting documentation will be denied for MA beneficiaries in the Fee-for-Service delivery system. NOTE: MA managed care beneficiaries should contact their specific managed care organization for their prior authorization requirements.