Prior Authorization Exemption Process for Hospital Outpatient Departments
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Medicare Provider Enrollment
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Madison, WI 53708-8248
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Medicare Provider Enrollment
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Madison, WI 53713-1834
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USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
P.O. Box 8248
Madison, WI 53708-8248
Overnight Delivery
WPS GHA
Medicare Provider Enrollment
1717 W. Broadway
Madison, WI 53713-1834
(866) 234-7331
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USPS Mailing Address
WPS GHA
Medicare Provider Enrollment
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Madison, WI 53713-1834
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Prior Authorization Exemption Process for Hospital Outpatient Departments
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Hospital Outpatient Departments (OPD) that 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 twelve-month period or until CMS elects to withdraw the exemption. To be eligible, OPDs need to submit at least ten 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 an exemption or withdrawal of an 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 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. 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.
Annual Assessment Cycle Starting January 1st
Quick Overview
Detailed Overview
Date | Action |
January 1st | Exempt providers do not submit PARs. PARs submitted will be rejected. Non-exempt providers are still required to submit PARs. |
August 1st | 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 have 45 days to review. |
November 2nd | 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 18th | Providers who received a notification of withdrawal from exemption may start to submit PARs. |
January 1st | Providers withdrawn from exemption return to the standard PA process and must have an associated PAR for submitted claims. |
Ten Claim Sample Review
Exempt OPDs will receive an ADR for a ten claim post-pay sample on finalized claims with dates of service on or after January 1st, through June 30th. OPDs have 45 days 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.
For more information, see the OPD Operational Guide
Prior Authorization Exemption Process Frequently Asked Questions (FAQs)
I received a letter stating that I am starting prior authorization exemption. What do I do now?
I received a letter stating I am now withdrawn from prior authorization exemption. What do I do now?
Why are my prior authorization requests (PARs) being rejected while on exemption?
What does it mean to opt out of exemption?
What are Additional Documentation Requests (ADRs)?
What is the prior authorization exemption Additional Documentation Request (ADR) timeline?
global-tags: J8A,J5A,Claim Review,Prior Authorization
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