Prior Authorization for Certain Hospital Outpatient Department (OPD) Services

The Federal Register established a prior authorization (PA) process as a condition of payment for certain covered hospital Outpatient Department Services (OPD).

This program is for Part A procedure billing only.

What needs to go through this program:

  • Certain procedures specified by CMS that take place in an Outpatient Hospital setting.
    • Services are allowed based on medical necessity

What does NOT need to go through this program:

  • Prescription drugs
    • Contact beneficiary’s Part D insurance for further assistance.
  • Repetitive Scheduled Non-Emergent Ambulance transport (RSNAT)
    • RSNAT is a Part B service, this is not the correct program
  • Oxygen or home medical equipment
    • These requests are DME requests
  • Radiology tests (MRIs, CTs, X-Rays)
    • There is currently no division within Noridian that does prior authorization for radiology testing.

The hospital OPD provider will submit the PA to their Medicare Administrative Contractor (MAC) jurisdiction.

The term requestor will be used throughout this page to describe the person or entity that submits the prior authorization request (PAR), documentation, and/or claims.

View the links below for further detail.

For questions, please contact Be sure to include the Beneficiary's MBI, PTAN, CPT/HCPCS code(s), UTN (unique tracking number), and the issue you are experiencing.


Last Updated Jul 12 , 2024