Guides / PA exemption
PA exemption Supplier exemption from required prior authorization — all PA programsThe DMEPOS prior authorization exemption: how it works and how to keep it
Citations verified against the CMS Medicare Coverage Database · Reviewed September 2026
Since June 1, 2026, a DMEPOS supplier with a strong prior authorization record can be exempted from submitting prior authorization requests (PARs) for items on CMS's Required Prior Authorization List. The exemption was created by CMS-1828-F, the calendar year 2026 Home Health final rule published in the Federal Register on December 2, 2025, and it is administered by the DME MACs — Noridian for Jurisdictions A and D, CGS for Jurisdictions B and C.
This guide covers who qualifies, how the annual cycle runs, what the opt-out is for, and what the MACs check to decide whether you keep the exemption the following year.
The requirements, with citations
The elements below are drawn from the cited CMS and DME MAC sources, not from AffirmDME's rules engine.
A provisional affirmation rate of at least 90% on initial requests
To qualify, a supplier must have submitted at least 10 initial PARs in the assessment window and received a provisional affirmation — the MAC's preliminary finding that a future claim will likely meet Medicare requirements — on at least 90% of them. The MACs calculate the rate across all PA programs combined, so a weak category pulls the whole number down.
CMS DMEPOS PA Operational Guide §6Eligibility is measured per PTAN and per jurisdiction
The MACs compute the rate by supplier PTAN (the Medicare provider transaction access number) and jurisdiction, and a supplier must reach eligibility for each PTAN and jurisdiction separately. A multi-state supplier can be exempt with Noridian and still submitting PARs to CGS.
Noridian — Prior Authorization Exemption ProcessAn annual June 1 – May 31 cycle, with letters by April 2
The first cycle runs June 1, 2026 through May 31, 2027, and later cycles follow the same June-to-May window. The DME MAC notifies suppliers of their status by mail postmarked no later than April 2 (Noridian also posts the notice in its portal), and CMS requires at least 60 days' notice before an exemption or a withdrawal takes effect.
CMS-1828-F fact sheet; Noridian exemption pageAn opt-out window for suppliers who prefer to keep submitting PARs
A supplier offered the exemption may decline it and continue submitting PARs, by sending an opt-out request to its MAC by fax, email, portal, or another electronic method. In the standing schedule the window is April 2 through April 30 and late requests are rejected; for the first cycle the MACs announced a later window, so confirm current dates on your MAC's exemption page.
CMS DMEPOS PA Operational Guide §6.2A 10-claim post-payment sample decides whether the exemption continues
On January 1 of the exemption year the MAC sends exempt suppliers an Additional Documentation Request (ADR) for a sample of 10 paid claims from the exempt period. The supplier has 45 days to respond, the MAC reviews within 45 days of receipt, and continued exemption requires a claim approval rate of 90% or better — plus at least 10 claims submitted and paid by November 30, or the exemption is withdrawn regardless.
CMS DMEPOS PA Operational Guide §6.1; CGS exemption pageExempt suppliers must not submit PARs during the cycle
PARs received from an exempt supplier during its exemption period are rejected, so claims for those items are submitted directly. Suppliers who did not meet the threshold continue submitting PARs as usual, and any claim for a required-PA item without a PAR decision is denied.
CMS DMEPOS PA Operational Guide §6.1What usually sinks these claims
- Treating the exemption as a documentation holiday — the 10-claim sample asks for the same order, face-to-face, and proof-of-delivery records a PAR would have
- Missing the 45-day ADR window on the January sample; late records are still reviewed, but they do not change a compliance rate the MAC has already finalized
- Fewer than 10 paid claims by November 30 in the exempt jurisdiction, which withdraws the exemption on volume alone
- Assuming exemption in one jurisdiction or PTAN carries to another — it is determined separately for each
- Sending the opt-out request after the window closes; late opt-outs are rejected
Know where each PTAN stands before the MAC tells you
AffirmDME tracks affirmation rate and exemption status by item, location, and PTAN — the same split the MACs use — so you can see which jurisdictions are on track for the 90% threshold and which need work before the next assessment.
Track affirmation ratesFAQ
Who qualifies for the DMEPOS prior authorization exemption?
A supplier that submitted at least 10 initial PARs during the MAC's assessment window and received provisional affirmations on 90% or more of them, calculated per PTAN and jurisdiction across all PA programs combined. The MAC tells you by letter; you do not apply.
Does an exempt supplier still need the same documentation?
Yes. The exemption removes the PAR step, not the coverage rules. Each January the MAC pulls a 10-claim post-payment sample and asks for the records; a claim approval rate under 90% on that sample ends the exemption at the next cycle.
What happens if my rate drops during the exemption year?
The MAC issues a Notice of Withdrawal on or after April 2, with at least 60 days before it takes effect. Suppliers who lose the exemption may start submitting PARs ahead of the June 1 cycle, and any claim for a required-PA item submitted on or after that date needs an associated PAR decision.
Can AffirmDME track my affirmation rate toward the exemption?
Yes. AffirmDME tracks affirmation rate and exemption status by item, location, and PTAN, so you can see which jurisdictions are on track for the 90% threshold and which need attention before the MAC runs its assessment.
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This guide summarizes Medicare requirements as implemented in AffirmDME's compliance engine, with citations to the governing sources. It is not legal or billing advice; LCDs and CMS policy change — always confirm against the current policy text linked above.
Also drawn on: CMS — DMEPOS prior authorization program (exemption page) · Federal Register — CMS-1828-F (Dec 2, 2025) .
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Unfamiliar term? The glossary defines ADR, SWO, UTN, PTAN and the rest; the PA List lookup checks any HCPCS code.