Medicare is adding a prior authorization requirement for new O&P suppliers this fall. Here is what changes and for whom.

On October 15, a new Medicare prior authorization requirement takes effect for certain orthotic and prosthetic suppliers. The Centers for Medicare and Medicaid Services is calling it probationary prior authorization, and it applies specifically to newly enrolled DMEPOS suppliers and to suppliers who are undergoing certain changes of ownership. If your clinic fits that description, claims for a defined list of orthotic items will require prior authorization before payment is approved.

If your supplier has been enrolled in Medicare for a while and has not recently changed ownership, this rule does not touch your current relationship.

What the rule does

CMS is authorized to impose a probationary period on newly enrolled DMEPOS suppliers under Section 1866(j)(3) of the Social Security Act and 42 CFR §424.527. That authority has been on the books. What changes October 15 is that CMS is applying a prior authorization step to specific items during that probationary window.

The probationary period runs for one year. It starts not at enrollment, but when the supplier submits its first claim for an item on the Probationary Prior Authorization List. So a supplier could be enrolled for several months before the clock starts, depending on what they bill.

The probationary prior authorization requirement stacks on top of existing prior auth requirements. Where prior authorization is already required for a given item, that requirement remains. The new rule adds a separate layer for suppliers in their probationary period, not a replacement.

CMS said it may update the list if new vulnerabilities arise.

Which items are on the list

The items covered are orthotic L-codes. The list includes:

AFO and KAFO codes: L-1902, L-1906, L-1971, L-2035, L-2132, L-2134, L-2136, L-4360, L-4361, L-4396, and L-4397.

Knee orthosis codes: L-1810, L-1812, L-1820, and L-1821.

Lower-limb orthosis codes: L-1652, L-1653, L-1686, and L-1690.

Spinal orthosis codes: L-0626, L-0627, L-0628, L-0630, L-0633, L-0635, L-0641, L-0642, L-0643, L-0649, and L-0720.

Upper-limb orthosis codes: L-3660, L-3670, L-3760, L-3762, L-3809, L-3908, L-3915, and L3960.

These are orthotic codes. Prosthetic components are not on this list. The rule targets categories where CMS has identified billing vulnerability among newer suppliers.

What this means in practice

For most people getting prosthetic or orthotic care from an established supplier, nothing about October 15 changes how your claims process. The rule is directed at suppliers, not at devices or diagnoses.

Where it matters is if you are currently being fit or followed by a supplier that recently enrolled in Medicare or recently went through a sale or ownership change. If your supplier falls into that category, and you need one of the items on the list, the supplier now has to obtain prior authorization before the claim clears. That step adds time. If the documentation isn’t submitted promptly or completely, coverage can be delayed.

If you are not sure whether your supplier is newly enrolled or has recently changed ownership, you can ask your clinic directly. They will know whether the probationary requirement applies to them.

One thing the rule does not change: your right to appeal a denial, or your supplier’s obligation to request prior authorization correctly. If a claim for a covered item is denied because prior auth wasn’t obtained, the issue sits with the supplier’s billing process, not with your coverage eligibility.

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This article describes a Medicare administrative rule published by CMS. It is not legal, insurance, or billing advice. For questions about how this rule applies to your specific coverage or claims, contact your supplier or your Medicare plan directly.