Prior Authorization Process for Certain Hospital Outpatient

3.10.2 - Prior Authorization Process for Certain Hospital Outpatient Department (OPD) Services (Rev. 937; Issued: 01-31-20; Effective: 03-02-20; Implementation: 03-02-20) A prior authorization process for certain hospital OPD services is described in 42 CFR §§419.80 through 419.89 as a method for controlling unnecessary increases in the volume of covered services. These sections establish requirements for the submission of a prior authorization request (PAR), the timeframes for the review of a PAR, and the process for CMS to exempt providers from prior authorization requirements. The list of hospital OPD services requiring prior authorization will be updated through formal notice-and-comment rulemaking. Technical updates to the list of services, such as changes to the name of the service or the HCPCS code, will be published on the CMS website. The CMS may elect to exempt a provider from this prior authorization process upon a provider’s demonstration of compliance with Medicare coverage, coding, and payment rules after semiannual assessments. Providers must reach a prior authorization provisional affirmation threshold of 90 percent or greater to be eligible for exemption. The CMS may suspend the outpatient department services prior authorization process requirements generally or for a particular service(s) at any time by issuing notification on the CMS website.