Prior Authorization

Exemption

Table of Contents

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Exemption

Exemption is a component of the hospital OPD PA program comprised of two cycles: the standard review cycle and the exemption cycle. Each cycle requires a 90% or greater compliance rate to achieve and maintain exemption status, demonstrating a provider's understanding of Medicare coverage, coding, payment rules and accurate claim submission. Please refer to each cycle outlined below for more details.

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Exemption Database

This self-service tool allows hospital OPDs or physician office staff responsible for submitting PARs, to check the exempt status of the Hospital OPD. The tool will only recognize the hospital PTAN (CCN) number. If the PTAN/CCN entered is not recognized, it is an indication that the OPD is not on the current exemption cycle and a PAR is required for all PA services.

Prior Authorization Exemption Status Inquiry Tool

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The Standard Review Cycle Process

To be eligible for exemption, OPDs must submit at least ten PARs during the standard review period (January 1 – September 30) and achieve a provisional affirmation compliance rate of at least 90% with initial submissions. Qualifying providers will receive an exemption notice by November 2 through mail, and it will also be displayed in NGSConnex.  Included with the exemption notice is an option to opt out of the exemption process which will return the OPD back to the standard review process’s PAR requirements. OPDs who do not qualify for exemption must continue submitting PARs.

If you are a requestor submitting on behalf of the OPD and are unaware of the OPD’s exemption status, please contact the OPD and request a copy of the exemption notification letter. PARs submitted during the hospital OPD’s exemption period will be rejected.

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Cycle Overview Date Cycle Details
January - September
  • NGS calculates ongoing compliance rate for completed PA reviews.
October 1
  • NGS will begin processing exemption notices.
November 2
  • NGS will send a written notice of exemption to eligible providers.
  • These notices will be displayed in the NGSConnex provider portal and mailed to the medical review address in the Medicare billing system.
January 1
  • Exempt providers should not submit PARs.

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Exemption Cycle Process

To maintain exemption, OPDs must have at least 10 finalized claims with PA services by June 30 and achieve a post-pay ADR compliance rate of at least 90%. Qualifying providers will be notified of exemption continuation by November 2 via mail and NGSConnex. The notice will also provide an option to opt out of the exemption process, reverting to the standard PAR review process.

Providers with fewer than 10 finalized claims between January 1 and June 30 will be notified in early August about their withdrawal from exemption and exclusion from the ADR process. PARs will be required for services on or after January 1. These providers can re-qualify for exemption the following year during the standard review process.

Cycle Overview Date Description of the Exemption Cycle
January 1
  • Exempt providers do not submit 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.
  • NGS has 45 days to review and issue results letters.
November 2
  • NGS will issue notification letters regarding continued exemption or withdrawal.
  • Providers must achieve a post-pay claim approval rate of at least 90% to continue their exemption.
December 18
  • Providers notified of exemption withdrawal may start submitting PARs.
January 1
  • Providers who are withdrawn or opt-out return to the standard PA process and must submit PARs for all PA services.

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Ten-Claim Sample ADRs

Exempt OPDs will receive ADRs for post-pay review of ten (10) finalized claims with dates of service from January 1 through June 30, covering all PA services. 

Key facts to remember:

  • ADRs can be viewed through NGSConnex or FISS/DDE, the Medicare billing system.
  • Hospital OPDs have 45 calendar days from the ADR issue date to submit documentation.
  • The NGS PA team will complete their review within 45 days of receipt of the requested documentation.
  • Documentation received after the 45 day ADR response time:
    • OPDs who submit additional documentation after the initial 45-day response timeframe will not have their compliance rate changed if NGS has already finalized the compliance rate and sent notification to the OPD.
    • The NGS PA team 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.

After the review of the ten-claim sample, OPDs will receive a notification regarding either the continuation or withdrawal of their exemption. MACs will be prepared to start accepting PARs from providers who are being withdrawn from exemption on December 18th. 

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How to Find and Respond to a Prior Authorization ADR

The National Government Services Part A PA department generates ADRs annually to assess compliance for exempt status retention. In addition, NGS PA conducts ABN validity reviews for denied claims that hold a GA modifier. Please review each ADR carefully, as each request includes documentation to submit and specific instructions for submission. Applicable reason codes are 58BTP, 58BPP, 58PNP, 58RHP, 58VEP, 58FCP, 58SNP, 58CVP, and 5HBO1.

To avoid claim processing delays, it is important providers respond to ADRs in a complete and timely manner. Listed below are guidelines and checklists that will assist with claim submission:

  • NGS recommends responding to ADRs within 35‒40 days of letter date (CMS allows providers 45 days of the ADR date). See the ADR Timeline Calculator available on our website for help with determining the target date that the requested medical records must be received by NGS.
  • The NGS self-service portal, NGSConnex, is the preferred method for ADR response submission and allows Part A and Part B providers to respond to ADRs electronically with no need to mail or fax a response to complete the ADR process. If you are a current user of NGSConnex, click on the link for the NGSConnex User Guide for step-by-step instructions on how to submit. If you are not a current user, sign up and get started.
  • If you mail in your ADR, please send each response separately and attach a copy of the corresponding ADR. Each response must be individually bundled.
  • Include all records necessary to support the services for the dates requested.
  • Records must be complete and legible. Be sure to include both sides of double-sided documents.
  • All services must include the necessary signatures and credentials of professionals. See the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 “Signature Requirements”.

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Steps to View and Print ADRs from FISS/DDE Provider Online System

  1. Access the claims through the Claims Inquiry screen/option.
  2. Type 01 at the FISS/DDE Online System Main Menu and then type 12 on the Inquiry Menu for claims.
  3. At the Claims Inquiry screen, type SB6006 in the S/LOC field and press <Enter>. All claims in the SB6006 status and location will be displayed, indicating an ADR has been generated.
  4. At the desired claim, type S to the left of the claim under the SEL field and press <Enter>.
  5. Locate the ADR letter on page 06 of the claim.

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Revised 7/7/2025