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January 12, 2023

Who Will Need to Submit a Prior Authorization Request for HOPD Services?

A Notice of Withdrawal of Exemption from Prior Authorization notification letter was sent to providers currently exempt; but unable to maintain a compliance threshold of 90% or greater. The providers receiving this notification letter will need to submit request for prior authorization.

Beginning December 18, 2022, providers in the following categories will be required to submit a prior authorization request for certain hospital outpatient department services starting January 1, 2023:

  • Providers who have withdrawn from the provider exemption list
    • Exempt providers who did not achieve a 90% threshold after a review of claims
    • Exempt providers who requested to be withdrawn from the list
  • Providers who did not achieve a 90% affirmation rate for prior authorization requests submitted for the year

When submitting a prior authorization request providers will need to:

  • Review the process for submitting a prior authorization request
  • Become familiar with the requirements for each service category
    • Review the HCPC codes which require prior authorization
    • Provide medical documentation to support medical necessity
  • Complete a prior authorization request form with all the appropriate information
    • Use the current form for the specific service category
    • My CGS Portal members can complete a request form online
  • Submit the prior authorization with all appropriate documentation via fax, mail, or esMD
    • Allow enough time for processing and review of requests

Prior authorization is a condition of payment. Procedures performed without a prior authorization may result in a denied claim.



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