Prior Authorization

Exemption

CMS has provided an updated timeline for the exemption process within the OPD Operational Guide. Providers who were notified of exemption on 5/1/2021 or 11/1/2021, were issued a one-time continuation notification on 12/20/2021. You may reference this letter in NGSConnex or contact the exempt OPD to request a copy. Please see the Updates to the Exemption Process below and Exemption Process Frequently Asked Questions located under Related Content.

Please refer to this Exemption Q&A Session, a Nationwide collaboration between the MAC OPD Educational Workgroup to ensure consistency in educational efforts regarding the Exemption Process.

Exemption Database

This is a self-service tool to allow both hospital or physician office staff responsible for submitting prior authorization requests (PARs), to check the exempt status of the HOPD. This tool will only recognize the hospital PTAN (CCN) number. If the PTAN entered is not recognized, it is an indication that a PAR is required. Please note: Physician, Ambulatory Surgical Center and Critical Access Hospital PTAN entries will not return results; however, a PAR is not required for these facility types. Only hospital outpatient departments billing with a Type of Bill (TOB) code 13x require prior authorization.

Prior Authorization Exemption Status Inquiry Tool

Updates to the Exemption Process

Hospital OPDs who demonstrate compliance with Medicare coverage, coding, and payment rules related to PA may be eligible for exemption. This exemption would remain in effect for a twelve-month period or until CMS elects to withdraw the exemption. To be eligible, OPDs must submit at least ten PARs during the standard review period and achieve a provisional affirmation compliance rate of at least 90% during an annual assessment. Notice of exemption or withdrawal from exemption will be provided at least 60 days prior to the effective date.

OPDs who do not qualify for exemption shall continue submitting PARs as usual. There will be continued assessment of an OPD’s compliance through their affirmation rates in October of each year. Exempt OPDs should not submit PARs during the exemption period. If you are a requestor submitting on behalf of the OPD and are unware of the OPD’s exemption status, please contact the OPD and request a copy of the exemption notification letter. Continued evaluation of claim approval rate through ADRs will occur in August of each year. Exempt providers will be given the opportunity to opt-out of the exemption process. If a provider chooses to opt-out, they will return to the standard review process and be required to submit PARs.

Annual Cycle Starting January 1

Quick Overview

Cycle Overview Date	Cycle Details
January - September	MACs calculate ongoing compliance rate on completed PA reviews.
October 1	MACs begin processing exemption process notices.
November 2	MACs send written notice of exemption to eligible providers.
January 1	Exempt providers should not submit PARs.
August 1	MACs send ADRs to exempt providers.
November 2	MACs send written notice of continued or withdrawn exemption.
January 1	PARs required for providers withdrawn from exemption.

Detailed Overview

Exemption Cycle Date	Description of Exemption Cycle
January 1	Exempt providers do not submitted PARs. PARs submitted will be rejected. Non-exempt providers are still required to submit PARs
August 1	Exempt providers will receive an ADR for a random ten claim post-pay review. Claim samples are selected from dates of service during the exemption period. Providers have 45 days to submit documentation. MACs has 45 days to review.
November 2	MACs will send notification letters for either continued exemption or withdrawal from exemption. Providers must achieve a greater than 90% claim approval rate with post-pay claim review to continue exemption.
December 18	Providers who received a notification of withdrawal from exemption may begin to submit PARs.
January 1	Providers withdrawn from exemption return to the standard PA process and must have an associated PAR for submitted claims.

Ten Claim Sample ADRs

Exempt OPDs will receive an ADR letter for a ten claim post-pay sample on finalized claims with dates of service on or after January 1st, through June 30th. Hospital OPDs have 45 calendar days from the ADR issue date to submit documentation. MACs will complete their review within 45 days of receipt of the requested documentation. OPDs who submit additional documentation after the initial 45-day response timeframe will not have their compliance rate changed if the MAC has already finalized their compliance rate and sent notification to the OPD. The MAC will still review late documentation, issue a review determination, and make a claim adjustment, if necessary. Claim denials are subject to the normal appeals process; however, overturned appeals will not change the OPD’s exemption status. Following the ten-claim sample review, OPDs will be notified whether they remain exempt or transition back to the standard review process of submitting PARs. PARs are required 60 days after the notification of withdrawal letter, which is the start of the standard cycle, (January 1st). MACs will be prepared to start accepting PARs from providers who are being withdrawn from exemption on December 18th.

*Providers who do not have a minimum of ten finalized claims with dates of service on or after January 1st, through June 30th, will not participate in the ADR process and will be withdrawn from exemption.

Prior Authorization Reminder

Exempt providers should not submit PARs for any procedures that are part of the OPD PA program. PARs voluntarily submitted will be returned with a rejection decision. Exempt providers will continue to be exempt from submitting claims with UTNs.