Hospital Outpatient Department Prior Authorization Exemption Process
Hospital outpatient departments (OPDs) who demonstrate compliance with Medicare coverage, coding, and payment rules related to prior authorization (PA) may be eligible for exemption. This exemption would remain in effect for a 12-month period or until CMS elects to withdraw the exemption. To be eligible, OPDs need to submit at least 10 prior authorization requests (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 calendar days prior to the effective date.
OPDs who do not qualify for exemption 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. PARs submitted during the exemption period will be rejected. Claims submitted while on exemption will not require a unique tracking number (UTN). The provider bills the claim using standard billing practices and does not enter previously assigned or invalid UTNs.
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. Continued evaluation of claim approval rate through additional documentation requests (ADRs) will occur in August of each year. ADRs are post-payment medical record reviews conducted on a random sample of 10 finalized claims for exempt providers.
Exempt providers will be given the option to opt-out of the exemption process. By opting out of exemption, providers will return to the standard review process and be required to submit PARs. An opt-out form is included with the exemption notification letter and must be returned to the MAC by November 30.
Annual Cycle Starting January 1
Overview
| Date | Process |
|---|---|
| January 1 |
Exemption cycle begins for providers who met the compliance rate threshold. Exempt providers do not submit PARs. PARs submitted for exempt providers will be rejected. Non-exempt providers are still required to submit PARs. Providers withdrawn from exemption return to the standard PA process and must have an associated PAR for submitted claims. |
| August 1 |
Exempt providers will receive an ADR for a random ten claim post-pay review. Claim samples are selected from dates of service January 1, through June 30 during the exemption period. Providers have 45 calendar days to submit documentation. MACs have 45 calendar 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 start to submit PARs in advance of the January 1 review cycle. |
| January 1 |
Exemption cycle begins for providers who met the compliance rate threshold. Exempt providers do not submit PARs. PARs submitted for exempt providers will be rejected. Non-exempt providers are still required to submit PARs. Providers withdrawn from exemption return to the standard PA process and must have an associated PAR for submitted claims.
|
10-Claim Sample ADRs
Exempt OPDs will receive an ADR for a 10-claim post-pay sample on finalized claims with dates of service on or after January 1, through June 30. The random sample is selected from finalized claims with dates of service during the exemption period. OPDs have 45 calendar days to submit documentation. MACs will complete their review within 45 calendar 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 10-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 calendar days after the notification of withdrawal letter, which is the start of the standard cycle, January 1. MACs will be prepared to start accepting PARs from providers who are being withdrawn from exemption on December 18. Claims with dates of service on or after January 1 must have an associated PAR and UTN.
Providers who do not have a minimum of 10 finalized claims with dates of service on or after January 1, through June 30, will not participate in the ADR process and will be withdrawn from exemption.
If you have questions regarding the exemption process or the notice of exemption letter that you have received, please contact PA customer service at: 855-340-5975.
Reference