Glossary / Affirmation and non-affirmation
Affirmation and non-affirmation Medicare DME termAffirmation and non-affirmation
The two outcomes of a DMEPOS prior authorization request: a provisional affirmation clears the claim to be paid, a non-affirmation does not.
When the DME MAC finishes a prior authorization review it issues one of two decisions. A provisional affirmation is, in the regulation's words, a preliminary finding that a future claim meets Medicare's coverage, coding, and payment rules. A non-affirmation means the documentation submitted did not meet those rules, and the decision letter explains which requirements were not met.
A provisional affirmation is not a payment guarantee. The claim can still be denied for technical reasons, such as a missing UTN or a claim that does not match what was authorized. It is also time-limited: the affirmation is valid for a set period that varies by item category, for example six months for power mobility devices.
A non-affirmation is not appealable, because it is not a payment determination. Instead you fix the gaps the letter identifies and resubmit, as many times as needed. If you deliver and bill anyway, the resulting claim denial does carry full appeal rights. Decision letters go to the supplier and can be sent to the beneficiary; the ordering practitioner can request a copy.
Common questions
What is the difference between a non-affirmation and a denial?
A non-affirmation is a pre-claim decision on a PA request; it cannot be appealed but can be resubmitted without limit. A denial is a decision on a submitted claim and starts the appeals process.
What usually causes a non-affirmation?
The letter says exactly which rules were not met. Common reasons are an incomplete or unsigned Standard Written Order, clinical notes that do not document the qualifying condition, or a face-to-face encounter outside the required window.
Why does my affirmation rate matter?
The prior authorization exemption is based on a 90 percent affirmation rate on initial requests, per PTAN and jurisdiction; AffirmDME tracks affirmation rate and exemption standing per location from the decisions you record.
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Sources: 42 CFR 414.234 — definition of provisional affirmation · CMS: DMEPOS Prior Authorization Operational Guide · Noridian JA DME: Prior Authorization for Power Mobility Devices . Definitions summarize public Medicare policy and are not legal or billing advice.
More terms
- ADR — Additional Documentation Request
- Prior authorization
- UTN — Unique Tracking Number
- SWO — Standard Written Order
- Face-to-face encounter
- DME MAC — Durable Medical Equipment Medicare Administrative Contractor
- Jurisdiction
- PTAN — Provider Transaction Access Number
- NPI — National Provider Identifier
- MBI — Medicare Beneficiary Identifier
- LCD — Local Coverage Determination
- NCD — National Coverage Determination
- Policy article
- HCPCS — Healthcare Common Procedure Coding System
- Length of need
- Prior authorization exemption
- Competitive bidding
- CMN and DIF — Certificate of Medical Necessity and DME Information Form
- Proof of delivery
- TPE — Targeted Probe and Educate
- Prepayment review