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July 22, 2021 - REVISED July 19, 2022

OPD Prior Authorization Provider Exemption Process

Provider exemption is granted to a hospital OPD provider if they have been able to demonstrate a provisional affirmation threshold of ≥ 90%. Each year exempt providers are reviewed to determine if they have maintained their threshold of ≥ 90% provisional affirmation rate.

The ADR Letters are Coming!

Providers who became exempt in May and November of 2021 will be receiveing ADR letters starting August 1, 2022. Exempt providers need to have submitted at least 10 claims by June 30, 2022 to be considered for their continued exemption status. If less than 10 claims were submitted by June 30, 2022, providers will be returned to the standard Prior Authorization cycle.

Exemption Process Cycle

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  1. August 1: Providers exempt in May and November 2021 will receive an additional document request (ADR) letter for a 10-claim sample
    1. Providers have 45 days to respond to the ADR letter and submit documentation
      1. CGS has 45 days to complete their review of documents received
  2. October 1-31: CGS will calculate the affirmation rate for all seven service categories combined and will notify providers with an affirmation rate of 90% or greater
  3. October 1-Novemebr 30: Hospital OPD providers have the option to opt out of the exemption process and continue submitting prior authorization requests
    1. Must submit opt-out request to CGS no later than November 30, 2022.
  4. November 2: Providers will receive a written 60-day notice if they have maintained their exemption status or will be withdrawn from the exemption list
    1. Providers will receive a Notice of Withdrawal of Exemption if their claim approval rate is less than 90%
    2. Providers will receive a Notice of Continued Exemption if they remain at a 90% or greater approval claim rating
  5. December 18: Providers who are no longer exempt must begin submitting prior authorization request for services beginning January 1, 2023
  6. January 1, 2023: The exemption cycle begins for providers who met the compliance threshold of 90% or greater
    1. Prior authorizations received from exempt providers will be rejected

Exemption Cycle Process:

Each year the cycle process starts over again on August 1. For exempt providers, their claims will continue to be reviewed and evaluated to determine their approval claim rate.  Claims will have needed to be submitted by June 30. They will receive an ADR letter requesting documentation for at least a 10-claim sample.

Providers who continue to be non-exempt will still be required to submit prior authorization requests for the designated seven services.  They will continue to be assessed for compliance for their affirmation rates starting in January of each year.

Tips to Remember

  • Exempt providers need to have at least 10 claims submitted and paid by June 30
  • Provider exemption cycle begins each year August 1 with the ADR notifications sent to all exempt providers
    • Respond to an ADR letter within 45 days or less with the requested documentation
  • Review claims to ensure all supporting medically necessary documentation is in place for the OPD procedure that was rendered
    • May have to get documentation from the prescribing physician
    • These claims may be reviewed during the exemption cycle process
  • Exempt providers do not need to submit prior authorizations
    • Providers receive a letter indicating their exemption status
  • Use myCGS portal to keep track of notifications, upload requested documentation, submit forms, and check the status of prior authorization requests or claims

Resources

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