Prior determinations: Know you’ll get paid before you operate

Why This Topic Matters

The article helps providers understand a Medicare process that can reduce uncertainty about payment for selected costly services before they are performed. It is relevant for practices that need to manage coverage risk, patient communication, and claim-related planning.

Article Sections

1. Overview of the prior determination rule

   Introduces the Medicare policy change and explains the general purpose of allowing advance review before selected services are performed. It also places the rule in the context of coverage and liability concerns.

2. Services covered by the final rule

   Describes the types of services and procedure categories that may be included under the final rule, along with the role of carrier-published eligible service lists. It also discusses how existing coverage policies are handled within the process.

3. Combat tight timeframes with ABNs

   Explains the timing limitations of the review process and discusses how beneficiary notice practices fit when coverage is uncertain. It addresses the interaction between prior determination requests and patient billing communication.