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July 27, 2023

Prior Authorization Timelines for HOPD Services

Prior authorization is a condition of payment. Claims submitted for services rendered without a prior authorization in place may receive a denial.

Types of Prior Authorizations Timelines

There are 3 types of prior authorization requests:

  • Initial
  • Resubmission
  • Expedited (initial or resubmission)

Initial and resubmission requests require 10 business days for review. Allow sufficient time for the request to be reviewed within the allotted 10 business days.

Expedited requests require 2 business days for review. Documentation needs to demonstrate that any delays could jeopardize the life and overall health of the beneficiary. If not, the request will be reviewed within 10 business days.

When you submit a prior authorization request, be sure to allow enough time for CGS to complete the review. Also, account for weekends or holidays (not included as business days) and non-affirm decisions (to address any issues and resubmit the request). If a request is submitted with a date of service that is less than 10 business days, there’s no guarantee it will be reviewed in time for the service.

Reasons for Potential Rejections/Non-Affirmed Decisions

  • Incomplete information on the request form
  • Wrong information on the request form
  • Conflicting information on the request form
  • No anticipated date of the procedure provided on the request form
  • Anticipated date of service is less than 10 business days
    • Example: Prior authorization request submitted July 5 with a requested date of service July 10
  • Requests submitted on the same day as the requested date of service
  • Requests submitted with the next day as the requested date of service
  • Request submitted after the service has already been provided
  • Illegible request form

Tips & Recommendations

  • Verify the procedure date and make sure there is enough time for CGS to process and review the request.
  • Allow yourself enough time in the event the prior authorization request receives a non-affirmed decision.
  • Review the documentation requirements and resources related to the HOPD service requested before submitting your prior authorization requests.
  • Use the internet browser to type on the prior authorization request form, select from the drop-down choices, and print. Do not save or download the form.
  • Handwritten forms need to be legible.
  • Double check the prior authorization request form to ensure all information is accurate.
  • Make sure the request form includes the appropriate HCPCS codes that require prior authorization for the service requested.

Resubmission Process

When resubmitting a prior authorization request for a non-affirmed decision:

  • Complete another prior authorization request form and indicate the type is a “resubmission”.
  • Type or write the latest non-affirmed UTN number in the UTN field. The UTN number can be found in the non-affirmed notification letter you received.
  • Gather ALL documentation for the request.
    • Documentation previously submitted with the prior request
    • Anything newly acquired
  • Submit the resubmission request with ALL documentation. Be sure to allow 10 business days for review.
    • If submitting via the myCGS portal, you will still need to upload ALL documents, not just what was newly acquired.

*If you received a rejection notification with no UTN, follow the process for an initial submission.


Prior Authorization Program for Certain Hospital Outpatient Department Services Operational GuideExternal PDF

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