CMS / Medicare / source directory

Hospital outpatient program — official procedure references

Hospital OPD bill-type boundary: This OPD program applies to hospital outpatient services billed as 13X. Other settings need their own program assessment, including the separate ASC demonstration. Emergency department exception: ET modifier or 045x revenue code excludes the emergency department service from this PA requirement; future medical review remains possible. Resubmission versus appeal: Before a claim is submitted, PA requests can be resubmitted without a numeric limit. A PA non-affirmation is not an appealable initial determination; a subsequently denied claim is distinct. Appeal does not waive required prior authorization: A claim denial for missing required PA is appealable, but the FAQ states payment cannot be made when no required request was submitted, even if the service otherwise meets coverage. Source checked 2026-10-15. Documentary verification only; no clinical review or individual coverage determination.

Source evidence

Documentary checks establish what the official source says, not clinical eligibility.

• opd faq · PDF page 3 — source checked 2026-10-15
• opd faq · PDF page 6 — source checked 2026-10-15

Research workspace

Evidence fingerprint: 7a3c7f50705f54f8db2123c1e9d95c2bf4c9c51acc2466e34ba87fd09fceff44