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Knowledge Center

Episode 162: Workgroup Voices, The Inner Workings of Prior Authorization

November 14, 2019

The purpose of this issue brief is to provide information regarding the Center for Medicare & Medicaid Services’ (CMS) Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging program. The program requires actions to be taken by both ordering and rendering providers for advance diagnostic imaging services (defined below), including reporting specific data related to the services in professional and institutional claims. The claims reporting requirements start on January 1, 2020 with an educational and operations testing period for one year. As of January 1, 2021, claims will be denied and not paid if the required AUC data are not reported. It is important to note that the AUC program is specific to the Medicare program and is only reported on claims for Medicare beneficiaries.

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