Provider Exemption(s)

The CMS may elect to exempt a hospital OPD provider from PA upon a provider’s demonstration of compliance with Medicare coverage, coding, and payment rules. This exemption would remain in effect until CMS elects to withdraw the exemption. CMS or its contractors would exempt providers that submitted at least 10 requests and achieve a PA provisional affirmation threshold of at least 90 percent during a annual assessment. By achieving this percentage of provisional affirmations, the provider would be demonstrating an understanding of the requirements for submitting accurate claims. Notice of an exemption or withdraw of an exemption will be provided at least 60 days prior to the effective date.

Exemption Timeline Example

Hospital outpatient departments can expect the following process:

January 1st

  • OPD that already earned exemption status for this year need not to submit PARs.
    • Any PARs submitted by an exempt OPD will be rejected.
  • Non-exempt OPDs are still required to submit PARs as usual.

August 1st

Review begins; ADR letters sent to exempt OPDs for 10 -claim post-pay review

  • OPDs that already earned exemption status for this year will receive an ADR for a random 10-claim post-pay review.
    • Claim samples are selected from dates of service during the exemption period.
      • OPDs MUST have at least 10 claims submitted and paid by June 30th to be eligible for this selection.
      • If the provider has less than 10 claims submitted, their exemption status will be withdrawn.
    • OPDs have 45 days to submit documentation.
  • Noridian has 45 days to review after documentation is submitted.

October

Noridian calculates affirmation rate of Non-exempt OPDs

  • Noridian will calculate the affirmation rate of "Initial" PARs for non-exempt OPDs in all service categories combined for the current calendar year.
  • OPDs non-exempt during the current calendar year that earned an affirmation rate of 90% or greater on the "Initial" PARs submitted will then earn exemption status for the following calendar year.

October 1st-November 30th

OPD can opt-out of exemption status

  • OPDs have the option to opt out of the exemption process and either lose or not obtain exemption status for the following calendar year.
  • Providers that choose to opt out of the exemption process must submit an opt-out request to Noridian no later than November 30th.
    • Late submissions will be rejected.

November 2nd

OPDs receive notice of withdrawal or continuation of exemption status

  • OPDs will receive a Notice of Withdrawal of Exemption if they:
    • Receive less than 90% claim approval from their 10-claim post-pay review
    • Failed to have a minimum of 10 claims to review for the ADR
  • OPDs will receive a Notice of Continued Exemption if they:
  • Receive 90% or greater claim approval from their 10-claim post-pay review.

December 18th

OPDs that lost exemption may begin to submit PARs for following year

  • OPDs who lost their exemption status for the following calendar year may start submitting PARs in advance of January 1st to avoid delay in timeliness of procedures scheduled in the following calendar year.

January 1st (following year)

Next exemption cycle begins; goes by calendar year

  • OPDs that already earned exemption status for this year need not submit PARs.
    • Any PARs submitted by an exempt OPD will be rejected.
  • Non-exempt OPDs for this calendar year are required to submit PARs as usual.

Recap

For OPDs who are not exempt, CMS will continue assessing a provider’s compliance through their PAR submission affirmation rates starting January of each year.

For exempt OPDs, CMS will continue to evaluate their claim approval rate through ADRs sent on August 1 of each year.

Resources

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