NCTracks
Updated PDN Clinical Coverage and Documentation Submission Policies Effective April 1, 2025
PDN Clinical Coverage policies require providers to submit the signed CMS 485 every 60 days for PDN beneficiaries. Providers are expected to submit the signed CMS 485 every 60 days. Effective April 1, 2025, for reauthorizations, GDIT will not look at previous PAs for CMS 485s.
Effective April 1, 2025, PDN providers will have a 7-business day grace period to submit all required PDN documentation. If the documentation is submitted and acceptable within 7-business days of the PA submission, GDIT will adjudicate the PA with the requested effective start date provided all clinical criteria are met. If the documentation is received after the 7-business day deadline, the effective PA start day will be the date of receipt of acceptable documentation provided all clinical criteria are met.
Example:
- PA submit date: 02/03/2025
- PA requested start date 02/12/2025
- RAI letter sent: 02/07/2025
- If the additional information received on or before 02/18/2025, the PA would be approved with the requested effective start date of 02/12/2025.
- If the additional information is received after 02/18/2025, the PA start date would be reduced to the date the final piece of documentation is received and all criteria is met. (Example: All requested additional information is received on 02/20/2025; therefore the PA start date is 02/20/2025.)