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February 10, 2026

Prior Authorization: Hospital OPD vs. ASC

CMS runs a variety of prior authorization and pre-claim review initiatives to help ensure compliance with Medicare rules, including:

  • Prior Authorization for Certain Hospital Outpatient (OPD) Services
  • Prior Authorization Demonstration for Certain Ambulatory Surgical Center (ASC) Services

Although these initiatives are similar, the processes are separate and distinct. If you submit prior authorization requests (PARs), please ensure you’re using the correct information and resources as described below.

Details Hospital OPD ASC
Program Nationwide process Includes selected states only
Jurisdiction Includes Kentucky & Ohio Includes Ohio (and other selected states) only Currently, providers in Kentucky don’t need to submit PARs.
Setting Applicable services provided in a hospital OPD Applicable services provided in an ASC
Requirement Prior authorization is a condition of payment. Prior authorization is voluntary. However, if you elect to bypass prior authorization, applicable ASC claims are subject to prepayment medical review.
Service Categories Implemented July 1, 2020:
  • Blepharoplasty
  • Botulinum Toxin Injections
  • Panniculectomy
  • Rhinoplasty
  • Vein Ablation
Implemented July 1, 2021:
  • Implanted Spinal Stimulators
  • Cervical Fusion with Disc Removal
Implemented July 1, 2023:
  • Facet Joint Interventions (July 1, 2023)
Dates of service on or after February 16, 2026:
  • Blepharoplasty
  • Botulinum Toxin Injections
  • Panniculectomy
  • Rhinoplasty
  • Vein Ablation
CPT/HCPCS Codes Use the Final List of Outpatient Department Services That Require Prior AuthorizationExternal PDF.

These are the only codes that require prior authorization. Don’t report any other codes on the PAR form.
Use the List of Ambulatory Surgical Center Services for Prior AuthorizationExternal PDF.

These are the only codes that require prior authorization. Don’t report any other codes on the PAR form.
PAR Submission Methods Choose one: Choose one:
Form(s)*
  • Use the Prior Authorization: OPD forms (esMD, fax, or mail submissions).
  • To avoid a possible rejection or delay in the review process, don’t download and save these forms for future use.
  • For each request, access the appropriate form on our website, complete all required information online, save, and print. This will ensure a unique barcode is generated and assigned.
  • Use the fax number or mailing address listed at the bottom of the form(s) only.
  • Use the Prior Authorization: ASC forms (esMD, fax, or mail submissions).
  • To avoid a possible rejection or delay in the review process, don’t download and save these forms for future use.
  • For each request, access the appropriate form on our website, complete all required information online, save, and print. This will ensure a unique barcode is generated and assigned.
  • Use the fax number or mailing address listed at the bottom of the form(s) only.
Resources See OPD Prior Authorization Forms & Resources for a complete list. See ASC Prior Authorization Forms & Resources for a complete list.

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