Guides / Non-affirmation
Non-affirmation Non-affirmed prior authorization decision — any required-PA itemAfter a non-affirmed prior authorization: resubmit, deliver with an ABN, or wait
Citations verified against the CMS Medicare Coverage Database · Reviewed September 2026
A non-affirmed prior authorization decision is the DME MAC's preliminary finding that a future claim for the item would not meet Medicare's coverage, coding, and payment rules. CMS's operational guide describes it as an incomplete request rather than a final answer: the MAC tells you what is missing, and you may resubmit as many times as it takes.
This guide covers how to read the decision letter, how resubmission and expedited review work, what the unique tracking number does, and how to think about delivering before an affirmation — with an Advance Beneficiary Notice of Non-coverage (ABN) or a secondary payer — versus waiting.
The requirements, with citations
The elements below are drawn from the cited CMS and DME MAC sources, not from AffirmDME's rules engine.
Read the detailed decision letter — it names the gap
The MAC sends the non-affirmation to the submitter by fax, mail, esMD, or its portal, and CMS requires it to state what required documentation is missing. Note that decision letters go to the supplier address on file with National Provider Enrollment, not the address on the request, so the person who filed the PAR may not be the one who receives the letter.
CMS DMEPOS PA Operational Guide §17, §4.1Fix the gap and resubmit — resubmissions are unlimited
CMS's guidance is to review the letter thoroughly, make the revisions, and resubmit through the standard channels; the operational guide states that unlimited resubmissions are permitted. Mark the request as a resubmission on the coversheet or in the portal so the MAC links it to the original, and the decision comes within five business days (not to exceed seven calendar days) of receipt.
CMS DMEPOS PA Operational Guide §5, §17.1.1The UTN is on every decision, affirmed or not
Each decision letter carries a 14-byte unique tracking number. On an affirmed decision it goes on the claim — Item 23 of the CMS-1500, or the REF segment with qualifier G1 on electronic claims. Noridian's page notes the decision and its UTN stay with the beneficiary, so an affirmation can transfer between suppliers.
CMS DMEPOS PA Operational Guide §16.1; Noridian required programsAsk for expedited review only when delay risks life or health
If waiting the standard timeframe could seriously jeopardize the beneficiary's life or health, the MAC makes reasonable efforts to decide within two business days. The request has to include medical documentation showing why; Noridian says a request without that justification is processed on the standard clock. On an expedited affirmation, hold the claim until the UTN arrives — a claim submitted before it will auto-deny.
CMS DMEPOS PA Operational Guide §5.1; Noridian PMD pageDelivering on a non-affirmation: the claim denies, then appeal rights attach
If you deliver and bill with a non-affirmed UTN on the claim, the MAC denies it and all appeal rights become available; the denied claim can also go to a secondary payer. For a beneficiary who is dually eligible, CMS says the non-affirmed decision itself satisfies the state's requirement to pursue Medicare first, so no Medicare claim is needed before billing Medicaid.
CMS DMEPOS PA Operational Guide §14.1, §18.2The ABN shifts liability only if it is valid
An ABN is the notice that tells the beneficiary Medicare is expected to deny the item and that they agree to pay. The operational guide addresses claims submitted with an ABN and the GA modifier where no PA decision exists: the MAC stops the claim and reviews the ABN's validity under its standard ABN policy. Do not treat the ABN as automatic protection — get the beneficiary's signature before delivery, and confirm current MAC guidance for your situation.
CMS DMEPOS PA Operational Guide §19.1What usually sinks these claims
- The same packet is resubmitted with a cover note instead of the specific element the letter named
- The resubmission is filed as a new initial request, so the MAC cannot tie it to the prior decision
- The item is delivered on a non-affirmed decision without a valid, signed ABN, leaving the supplier holding the cost
- Expedited review is requested without documentation of the life-or-health risk, so it runs on the standard clock anyway
- A claim is submitted before the UTN arrives on an expedited decision and auto-denies, forcing a reopening request
Turn the letter into a fix list
Upload the corrected records and AffirmDME re-runs the readiness checklist against the same rules, flags what is still missing, and reaches out to the prescriber by fax or DocuSign for the piece the MAC asked for.
See missing-document detectionFAQ
How many times can I resubmit a prior authorization request?
As many as needed. CMS's operational guide states that unlimited resubmissions are permitted. Each one is reviewed within five business days (not to exceed seven calendar days) of receipt.
Is the resubmission reviewed faster than the original?
No — under the current operational guide, initial requests and resubmissions share the same timeframe of five business days, not to exceed seven calendar days. Only an expedited request, justified by a documented life-or-health risk, has a shorter two-business-day target.
Should I deliver anyway or wait for the affirmation?
If the letter names a fixable gap, resubmitting is usually faster and cheaper than a denial-and-appeal path. Delivering first makes sense when the beneficiary has a secondary payer that will cover the item on a Medicare denial, when the patient is dually eligible, or when the beneficiary has signed a valid ABN and understands they may owe the cost. Whatever you choose, keep the UTN on the claim.
How does AffirmDME help after a non-affirmation?
Add the corrected records to the case and AffirmDME re-runs the per-item readiness checklist and missing-document detection against the same rules, with citations. If the gap is a practitioner note or a signature, prescriber outreach by fax and SWO e-signature through DocuSign can request it from the office without a phone chase.
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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.
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Unfamiliar term? The glossary defines ADR, SWO, UTN, PTAN and the rest; the PA List lookup checks any HCPCS code.