CMS Will Exempt High-Performing DME Suppliers From Prior Authorization Starting Now

The offer: stop submitting prior auth requests

Buried inside the CY 2026 Home Health Prospective Payment System final rule, CMS-1828-F, is a provision that has nothing to do with home health rates and everything to do with how DME suppliers get paid. Suppliers who maintain a prior authorization approval rate of 90% or higher can now be exempted from submitting PA requests at all, for an entire year at a time.

CGS, the DME MAC for Jurisdictions B and C, laid out the mechanics in January: if a supplier's PA approval rate hits 90% or higher, they get the option, each year, to skip prior authorization for that year's claims. It sounds like exactly what suppliers have been asking for since the requirement first expanded. Less paperwork before the equipment ships. Faster cash. One less place for a payer to sit on a claim.

It is also, according to at least one industry compliance voice, not quite the gift it looks like. "Not everything that looks like a gift turns out to be one," is how ACU-Serve's chief compliance officer framed it when the rule dropped. That framing is worth sitting with, because the exemption doesn't remove scrutiny from your documentation. It just moves the scrutiny to after the money has already left CMS's hands.

How the exemption actually gets calculated

The 90% threshold sounds like a single number, but it isn't applied that way. A DME supplier has to reach it for each PTAN and each MAC jurisdiction separately. Run locations in two jurisdictions, and one clean team doesn't carry the other. Every location has to earn its own exemption, which means a single office with a documentation problem stays inside the prior authorization requirement even while the rest of the company gets to skip it.

Suppliers found out where they stood for the first cycle by early April, when DME MACs were required to send notice of exemption status. From there, anyone who qualified but preferred to keep submitting PA requests anyway had a window to opt out, originally through April 30, later pushed to May 26 after CMS extended it. That extension alone tells you something: a meaningful number of suppliers who'd earned the exemption weren't rushing to use it.

"A 90% approval rate is not amnesty. It's a standing invitation for someone to check your math after the money is already gone."

What you're trading, and what you're not

The part of this rule that matters most for an intake team isn't the exemption itself. It's what replaces the review you're skipping. Under standard prior authorization, a MAC looks at your CMN, DWO, and clinical documentation before the claim pays and tells you, in writing, whether it's affirmed. Get it wrong, and you find out before the equipment goes out the door, or at worst before the money moves. Under the exemption, that check disappears. In its place, DME MACs run an annual post-payment medical review, pulling a sample of your paid claims and grading them against the same 90% bar, after the fact.

Read that table the way a compliance officer would. Prior authorization is annoying, but it's a known cost paid up front. The exemption swaps a predictable pre-payment check for an unpredictable post-payment one, where the same documentation gap now shows up as money CMS wants back, not a request you get to correct. That's the calculation behind why some suppliers who qualified are choosing to stay in the program they were just excused from.

The codes your 90% now has to cover

Whichever track you're on, the list of equipment your documentation has to hold up for just got longer. On January 13, 2026, CMS published updates to the Master List, the required Face-to-Face and Written Order Prior to Delivery list, and the required prior authorization list, effective April 13. Eighteen HCPCS codes were added to the Master List overall. Eight oxygen-related codes, including stationary and portable systems and oxygen concentrators, joined the required F2F/WOPD list because of high improper payment rates flagged by the CERT program.

Seven codes were added to the required prior authorization list outright: five orthoses, including a lumbar-sacral orthosis and several knee and ankle-foot orthoses, and two pneumatic compression device codes. CMS's stated reason for the orthoses was improper payment rates between 35% and 57%, along with documented fraud schemes. For the compression devices, the rate cited was as high as 78.9%. Those aren't rounding errors. They're the kind of numbers that explain why CMS is willing to hand out exemptions with one hand while tightening the net with the other.

What your intake team should confirm this week

Whether you're exempt, opted out, or waiting to see where next year's numbers land you, the documentation bar is identical. The following is what actually moves an approval rate, based on the elements DME MACs and post-payment reviewers check first.

The exemption doesn't lower the bar. It removes the referee.

It's tempting to read a 90% threshold as generous. In practice, it's the same standard DME suppliers have always been held to, minus the part where someone tells you if you've slipped before your money is at risk. That's a harder position to be in, not an easier one, especially for suppliers processing high volumes of recurring orders where a single documentation habit, good or bad, repeats itself hundreds of times a month.

Whatever got a supplier to 90% this spring was usually a team working carefully, not a system built to catch problems before they became a pattern. The exemption doesn't change that underlying gap. It just changes what happens when the gap eventually shows up: a request for more information, instead of a demand to send money back.

What to do this week

1. Pull your current PA approval rate, broken out by PTAN and jurisdiction

If you don't already have this split out, ask your billing team or DME MAC portal for it directly. A blended number can hide a location that's nowhere near 90%, or one that's carrying the rest of the company.

2. Cross-check your CMN, DWO, and F2F documentation against the April 13 code updates

If any of the seven newly required PA codes or eight newly required F2F/WOPD oxygen codes appear in your order volume, confirm your intake checklist has already been updated to reflect them. Several suppliers we've spoken with were still working from the pre-April reference sheet as late as June.

3. Make the opt-out decision on purpose, not by default

If you're eligible for exemption, weigh the predictability of staying in prior authorization against the cash-flow benefit of skipping it. There isn't a universally correct answer here. There is a wrong way to decide it, which is not deciding at all and letting the exemption apply because nobody flagged the deadline.

The exemption is real, and for a supplier with genuinely consistent documentation, it can mean faster cash and less administrative overhead. But it was never designed to reward suppliers for having good paperwork once. It's designed to keep rewarding them for having good paperwork every single month, with fewer people checking along the way.