Glossary / Prior authorization exemption
Prior authorization exemption Medicare DME termPrior authorization exemption
Suppliers with a 90 percent affirmation rate on 10 or more PA requests can skip PA for a year, per PTAN and jurisdiction; the first cycle began June 2026.
The prior authorization exemption lets a DMEPOS supplier that has shown it follows Medicare's coverage, coding, and payment rules stop submitting prior authorization requests for items on the Required List. 42 CFR 414.234 provides an exemption for a supplier that achieves a rate of payable claims of at least 90 percent during an initial or periodic review, remaining in effect until CMS withdraws it. CMS finalized the operational process in the CY 2026 home health rule (CMS-1828-F) in December 2025.
For the first cycle, the DME MACs measured suppliers that submitted at least 10 initial PA requests between June 1 and November 30, 2025, and reached a 90 percent affirmation rate. Compliance is calculated separately for each PTAN and jurisdiction. Suppliers were notified by April 2, 2026, and the first exemption cycle runs June 1, 2026 through May 31, 2027; later cycles follow the same June-to-May calendar. A supplier can opt out.
Exemption does not relax documentation. Exempt suppliers still must hold the SWO, the face-to-face record, and proof of delivery, and during the exemption year the MAC runs a post-payment review on a sample of paid claims, requested by ADR, to confirm the rate stays at 90 percent. The MACs give at least 60 days' notice before an exemption takes effect or is withdrawn.
Common questions
How is the affirmation rate calculated?
The DME MACs count initial PA requests in the assessment window, per PTAN and jurisdiction, and look for 90 percent affirmed. Fewer than 10 requests means no assessment and no exemption.
Can I lose the exemption mid-year?
Yes. The MAC samples paid claims through a post-payment ADR during the cycle; fall below the compliance rate, or fail to respond, and the exemption is withdrawn with at least 60 days' notice.
How do I know where I stand?
Your MAC portal shows your PA decision history and exemption status; AffirmDME tracks affirmation rate and exemption standing per location from the decisions you record.
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Sources: 42 CFR 414.234 — supplier exemption · CMS fact sheet: CY 2026 Home Health final rule (CMS-1828-F) · Noridian JA DME: Prior Authorization Exemption Process . Definitions summarize public Medicare policy and are not legal or billing advice.
More terms
- ADR — Additional Documentation Request
- Prior authorization
- Affirmation and non-affirmation
- 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
- Competitive bidding
- CMN and DIF — Certificate of Medical Necessity and DME Information Form
- Proof of delivery
- TPE — Targeted Probe and Educate
- Prepayment review