Exemption
Table of Contents
- Exemption
- Exemption Database
- Updates to the Exemption Process
- Annual Cycle Starting January 1
- Ten Claim Sample ADRs
- Prior Authorization Reminder
- Related Content
Exemption
CMS has provided an updated timeline for the exemption process within the OPD Operational Guide. NGSConnex users will be able to access exemption notifications within the portal when attempting to initiate a PAR, or obtain a copy from the exempt OPD. Please see the Exemption Process outline below and Exemption Process FAQs 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 hospital OPDs or physician office staff responsible for submitting PARs, to check the exempt status of the Hospital OPD. 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 TOB code 13x require PA.
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. 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's OPD exemption period will be rejected. 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 for completed PA reviews. |
| October 1 | MACs begin processing exemption notices. |
| November 2 | MACs send 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. |
| 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 or for those who opted out of the process. |
Detailed Overview
| Exemption Cycle Date | Description of the Exemption Cycle |
|---|---|
| January 1 |
|
| August 1 |
|
| November 2 |
|
| December 18 |
|
| January 1 |
|
Ten Claim Sample ADRs
Exempt OPDs will receive an ADR letter for a ten claim post-pay sample for 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. PARs will be required the following January.
Prior Authorization Reminder
Exempt providers are exempt from submitting claims with UTNs. 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 rejected decision.
Related Content
- Additional Documentation Request (ADR) Cover Sheet
- ADR Documentation List by Reason Code
- OPD Operational Guide
- Prior Authorization for Certain Hospital Outpatient (OPD) Services
- The Exemption Process Frequently Asked Questions
Please share your thoughts about your experience with our Prior Authorization process.
Revised 5/3/2024