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Provider Exemption Process

CGS will assess hospital outpatient departments (OPDs) that submit prior authorization requests (PARs) on an annual basis. OPDs that demonstrate compliance with Medicare coverage, coding, and payment rules related to the prior authorization program are eligible for exemption.

Exemption Timeline

Annual Cycle (January 1 – September 30)

October 1st – MACs calculate the affirmation rate of initial prior authorization requests (PARs) sent January 1st, and after and notifies exempt providers with an affirmation rate greater than 90%.

November 2nd – Exempt providers receive 60 days’ notice prior to the beginning of the exemption cycle.

November 30th – Exempt providers that wish to opt-out of the exemption process must submit an opt-out request by November 30th

January 1st – The exemption cycle begins. Exempt providers should not submit prior authorization requests.

August 1st – To determine continued compliance, exempt providers will receive an additional documentation request for a 10-claim sample from the exemption period.

November 2nd (On or before) – Providers will receive a notice of withdrawal from exemption, if applicable. Providers with less than a 90% claim approval rate during the 10-claim postpayment review will be withdrawn and returned to the standard PA cycle.

December 18th – Providers that did not meet the 90% claim approval rate will no longer be exempt and are required to submit prior authorization requests.

December 18th – Providers that are no longer exempt must have an associated Prior Authorization for any claim submitted on or after December 18th. CGS notifies providers that achieved a 90% or greater claim approval rate during postpayment review of their continued exemption effective December 18th.

* Hospital OPDs have 45 days to respond to the ADR and CGS will complete the review within 45 days of receipt of the requested documentation. Additional documentation submitted after the initial 45-day response timeframe will not change the provider compliance rate if CGS has already finalized it and sent notification. CGS will still review late documentation, issue a 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.

Additional information is available in the Exemption Article.

If you have questions related to the hospital OPD prior authorization and/or provider exemption processes, please email them to:


Who Will Need to Submit a Prior Authorization Request for HOPD Services?


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