Part A OPD Prior Authorization Exemption Process Questions and Answers - JF Part A

Q1: How many days' notice will I receive before I switch from Prior Authorization Request (PAR) submissions to an exemption cycle?
A1: Medicare Administrative Contractors (MACs) will provide a 60-day notice prior to any transition period, continuation, or withdrawal from exemption.

Q2: I received a letter stating that I am starting exemption. What do I do now?
A2: PARs should not be submitted and will be rejected during the exemption cycle starting May 1 or November 1. Claims submitted while on exemption will not require a unique tracking number (UTN). Please follow the instructions in the exemption notification letter

Q3: I received a letter stating I am now withdrawn from exemption. What do I do now?
A3: OPDs may resume submitting PARs beginning December 18th for procedures scheduled to take place the following calendar year. Your PAR affirmation date will be monitored for the next exemption cycle.

Q4: Why are my PARs being rejected while on exemption?
A4: PARs are not required while an OPD facility is on exemption, therefore any PAR submitted will be returned with a rejection decision. PARs should not be submitted for the purpose of obtaining a rejection letter for medical record keeping.

Q5: How do I bill PA claims without a UTN during the exemption period?
A5: PA services that were performed during the exemption period should follow the same billing practices used prior to the start of the exemption period. Applying previously used UTNs or invalid UTNs may delay processing of your claim.

Q6: Towards the end of the exemption cycle the MAC conducts a 10-claim post payment review. How are the claims selected?
A6: The 10-claim sample is based on claim dates of service during the exemption period. This means that the claims selected will be from the timeframe in which you were exempt.

Q7: Does the exemption process exempt the OPD facility from all OPD prior authorization services?
A7: Yes. If you receive a notice of exemption, it applies to all services under the OPD prior authorization program.

Q8: If an exempt provider submits a PAR on December 21st but it is non-affirmed and the provider then becomes exempt on January 1st, does the provider need to resubmit the PAR? Will that resubmission reject if it is past the exempt start date?
A8: You do not need to resubmit if the procedure is performed after the start of the exemption period. If you do resubmit the PAR on or after January 1st, it will be rejected.

Q9: If I am part of an exempt OPD facility, but during ADR review, it is determined that I no longer meet the requirements to remain exempt, when do I need to resume submitting PARs and begin adding a UTN to my claims?
A9: MACs will start accepting PARs from OPD facility who are withdrawn from exemption on December 18th. Claims with dates of service on or after January 1st require a UTN for nonexempt providers.

Q10: What does it mean to opt-out of exemption?
A10: CMS has established a rule that allows OPD facility to remain in the standard cycle and continue to submit PARs. The OPD facility will receive a notice of exemption if they achieved a greater than 90% PAR affirmation rate. An opt-out form will be included with the exemption notification letter. The form must be submitted to the MAC by November 30th. Late requests will be rejected.

Q11: What are ADRs?
A11: Additional Documentation Requests: ADRs are issued based on a specific claim submitted to your MAC. The ADR will specify the beneficiary and date of service and include a list of suggested documentation for a particular service to submit to your MAC that would support payment of your claim.

Q12: How many claims will be selected for ADR review?
A12: Your MAC will randomly select ten post-payment claims for the ADR review.

Q13: What is the ADR timeline?
A13: The first ADR for exempt providers will be sent on August 1st. The OPD facility has 45 days to submit the documentation, and the MAC has 45 days to review the documentation and make a determination. Notification of withdrawal will be sent out no later than November 2nd.