How DMEPOS Probationary Prior Authorization Affects Orthotics and Prosthetics Billing

If you are someone with an O&P practice who has enrolled in Medicare recently, opened a location under a new PTAN or changed hands, you need to be extremely careful, as the way you bill certain braces may have changed. Starting this month, October 15, 2026, CMS requires probationary prior authorization (PPA) for a list of orthoses supplied by DMEPOS suppliers whose Medicare enrollment is approved on or after that date. It also applies to all O&P suppliers where there is a change of ownership effective on or after that date.

So if you are managing your orthotics and prosthetics billing, check your enrollment notices and confirm your status with your DME MAC to avoid confusion. In fact, for suppliers under PPA, a knee orthosis or spinal brace on the list can’t be billed until the DME MAC has reviewed and affirmed a prior authorization request.

What Actually Changed on October 15, 2026 for Orthotics and Prosthetics Billing?

Probationary prior authorization, as it is commonly called, is an ongoing CMS program and not a single October-to-October window. Here, each affected supplier serves its own one-year probationary period, and it is not the same for all, as the dates differ from supplier to supplier.

Prior authorization under PPA is a condition of payment. For a listed item, the supplier must submit a prior authorization request (PAR), receive a provisional affirmation and even put the unique tracking number (UTN) from the decision on the claim. PPA doesn’t change medical necessity or documentation rules. It moves the review to before delivery.

PPA also doesn’t replace Medicare’s existing prior authorization program for certain DMEPOS items. Thus, one needs to follow both.

Related Reading: Creating a Master Plan to Overcome Prosthetics Billing Challenges 

Which O&P Suppliers and New Locations Are Affected?

PPA applies according to how and when a supplier enrolled in Medicare and not how long the business has been around. Under the CMS FAQ, two groups are subject to it:

• Newly enrolled suppliers whose Medicare enrollment is approved on or after October 15, 2026.
• Suppliers with a qualifying change of ownership effective on or after October 15, 2026.

In fact, CMS describes a change of ownership broadly. It can include a purchase, acquisition, merger, consolidation or lease, the creation of a new legal entity, a change in owners, a new tax identification number, or an asset sale tied to the Medicare business. It is up to CMS to decide through the enrollment process whether a particular transaction qualifies.

Expanding O&P groups should also check the rules for additional locations. A location that enrolls separately on or after October 15, 2026, and receives its own PTAN is treated as newly enrolled, even when the parent company is already a Medicare supplier. The existing location’s enrollment and PTAN history generally do not carry over to the newly enrolled location.

Existing suppliers that haven’t completed a new enrollment or gone through a qualifying change of ownership are not subject to PPA. CGS also notes that retail pharmacies and grocery stores are excluded.

When the One-Year Probationary Period Begins

According to the CMS FAQ, the probationary year begins when the supplier submits its first claim and ends one year later. Suppliers may have different probationary start and end dates, depending on when they submit their first claims.

CGS’s PPA page describes the year as running from the supplier’s start date. The CMS FAQ states that the period begins with the first claim. Confirm supplier-specific dates with the responsible contractor.

Which 38 Orthosis Codes Are Included?

The PPA list covers 38 orthotics HCPCS codes across five categories:

The list does not end here. It also includes two other non-orthosis codes for osteogenesis stimulators (E0747, E0748), thus bringing the full list to 40. Also, being in the healthcare business and managing orthotics and prosthetics billing, we must not forget that CMS can add codes if it identifies new vulnerabilities. So anytime you are billing for orthotics and prosthetics items, check the current PPA list before you deliver the particular item instead of relying on a saved copy.

What Documentation Should a PPA Request Include?

The DME MAC reviews the request against applicable Medicare coverage, coding and documentation requirements, including the LCD and policy article for the particular orthotics billing. In fact, the documentation that one needs to submit includes:

• Standard written order (SWO) – This is where the document deals with the beneficiary’s name or Medicare Beneficiary Identifier along with the order date. Also, a general description of the item and the quantity to dispense if applicable. Even the treating practitioner’s name or NPI as well as the treating practitioner’s signature is important here. Of course, the order timing depends on the item, where some items carry a written-order-prior-to-delivery requirement, so follow the applicable PA checklist and item-specific rules.
• Treating practitioner records – These records must support your medical necessity. They should show the diagnosis, the functional limitation the orthosis addresses as well as the specific findings the LCD requires for the particular type of device. A note that says only the patient needs a knee brace won’t meet the bar anymore in such cases of orthotics billing services.
• Item-specific documentation – The DME MACs publish documentation checklists for ankle-foot and knee-ankle-foot orthoses, knee orthoses, spinal orthoses, and replacement orthoses within the reasonable useful lifetime. You need to check each request against the matching checklist before sending it.

Also, if you are an O&P practice, it is no secret that the gaps show up in the referring practitioner’s notes rather than the supplier’s paperwork. Thus, the DME MACs publish “Dear Physician” letters for orthoses, and sharing the relevant letter may help the referral source understand which clinical records are needed.

How to Submit a Request and Expected Review Timeframes

PPA requests follow the same procedures as Medicare’s existing DMEPOS prior authorization program, and CGS lists these channels:

• Standard requests: the DME MAC provider portal (such as myCGS), or the prior authorization coversheet with records by mail, fax or esMD.
• Expedited requests: the portal, or the coversheet by fax or esMD. Mail is not listed for expedited requests.

The portal is usually the fastest way to submit and to check status. So once the basics are settled, confirm the channel options with your own DME MAC, since jurisdictions publish their own instructions.

Standard review – The DME MAC sends a detailed decision letter by the fifth business day, and never more than seven calendar days after it receives the request. The same clock applies to resubmitted requests.

Expedited review – If waiting for a standard decision could jeopardize the beneficiary’s life or health, you can ask for expedited review and include evidence of the urgency. The DME MAC will make reasonable efforts to send a written decision within two business days.

Custom-fit and off-the-shelf codes – Some orthoses have a custom fitted code and a corresponding off-the-shelf code. When both require prior authorization, CGS says you may list both corresponding codes on one request. If the submitted request lists the wrong HCPCS code, you need to submit a new request for the correct code and wait for its UTN before delivery.

After the Decision: Non-Affirmations, Delivery Deadlines and UTN Billing

Being a DMEPOS supplier and managing this complex process can be challenging unless you have help from professionals. In fact, for years SunKnowledge has helped many with orthotics and prosthetics billing, ensuring a seamless transaction. Here is what suppliers should do after a decision:

Urgent Orthosis Exception: When to Use the ST Modifier

The PPA requirement for orthoses on the list can be set aside in one narrow situation: when even the two-business-day expedited review would delay urgently needed care and put the beneficiary’s life or health at risk. In that case CMS suspends the requirement, and the supplier bills the claim with the ST modifier.

Every ST claim goes through 100% prepayment review, so the records have to show why the patient couldn’t wait. Use it for real emergencies only. A clinic that adds ST to get around a slow referral source is setting itself up for denials.

What Are the Pre-Delivery Checklists for Newly Enrolled O&P Suppliers?

1. Confirm whether your enrollment, separately enrolled location or ownership change falls under PPA.
2. Check the HCPCS code against the current PPA list and the Required Prior Authorization List.
3. Collect the SWO and practitioner records and check them against the DME MAC checklist.
4. Submit the request and track every single decision.
5. Deliver within the 60-day validity period, or submit a new request.
6. Keep proof of delivery on file after the item is delivered.
7. Bill the claim with the UTN.

Related Reading: How to Prevent HCPCS Code Drift in Orthotics Billing 

How SunKnowledge Supports the Process and the Complex Orthotics and Prosthetics Billing

For a newly enrolled O&P supplier, PPA adds an authorization step between the fitting and the claim. Our experts handle the stretch from reviewing orders and practitioner notes against the applicable requirements before submission. They also follow up with referral sources for missing records, submit requests, and track each UTN and its validity period to help the supplier identify approaching authorization deadlines, so you can focus on efficient patient care. Our orthotics and prosthetics billing services even cover the rest of the cycle, from eligibility checks through denials and A/R.

Looking for a dedicated partner to manage your complex orthotics and prosthetics billing services? Get in touch with our experts today over a no-commitment call and see the difference in a month.

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