Review and Decision Timeframe Update

Review Decisions and Timeframes
Effective January 1, 2025, the Centers for Medicare & Medicaid Services (CMS) will reduce the timeframe requirements for Medicare Administrative Contractors (MACs) to provide a hospital outpatient department (OPD) prior authorization request (PAR) provisional affirmed or non-affirmed decision within seven calendar days of receipt of the request.

Initial Submission
The first PAR sent to the contractor for review and decision. The MAC will complete its review of medical records and send an initial decision letter that is either postmarked or faxed within seven calendar days following the receipt of the initial request.

Resubmission
Any subsequent resubmissions to correct an error or omission identified during a PA decision. A resubmitted PAR is a request submitted with additional or updated documentation after the initial PAR was non-affirmed. The MAC will postmark or fax notification of the decision of these resubmitted requests to the provider or beneficiary (if specifically requested by the beneficiary) within seven calendar days of receipt of the resubmission request.

Expedited
A PA decision that is performed on an accelerated timeframe based on the MAC determination that delays in review and response could jeopardize the life or health of the beneficiary. If the MAC substantiates the need for an expedited decision, the MAC will make reasonable efforts to communicate a decision within two business days of receipt of the expedited request.

Resource: Outpatient Department Guide (PDF)