Before your doctor can provide specific services, prior authorization from Medicare may be necessary. Depending on your plan type, you might need prior approval to see a specialist.
So, which services and types of plans require prior authorization? Below, we’ll explain what you need to know.
What is Prior Authorization for Medicare
Prior authorization means your doctor must get approval before providing a service or prescribing a medication. Now, when it comes to Advantage and Part D, coverage is often plan-specific. Meaning, you should contact your plan directly to confirm coverage.
Medicare Part A Prior Authorization
Medicare, including Part A, rarely requires prior authorization. If it does, you can obtain the forms to send to Medicare from your hospital or doctor. The list mostly includes durable hospital equipment and prosthetics.
Medicare Part B Prior Authorization
Part B covers the administration of certain drugs when given in an outpatient setting. As part of Medicare, you’ll rarely need to obtain prior authorization.
Although, some meds may require your doctor to submit a Part B Drug Prior Authorization Request Form. Your doctor will provide this form. Once the request gets approval, coverage begins.
Often, even top Part D prescription drug plans need prior authorization for coverage on specific drugs. Different policies have varying rules, so you’ll need to contact the carrier directly to confirm coverage.
Most Part D plans have forms you can download online. The online option is a useful way to print the documents and take them to your doctor. Your doctor can help you correctly complete the form.
Also, recipients may directly contact their Part D plan and ask for a mail-in form. You can find the number for Member Services on your plan’s member ID card.
Medicare Advantage Prior Authorization
To obtain out-of-network, specialist, and emergency care, Medicare Advantage recipients may need prior authorization. Unfortunately, if Medicare doesn’t approve the request, the Advantage plan typically doesn’t cover any costs, leaving the full cost to you.
Reports have shown that as many as four out of five members with Advantage plans require prior authorization for certain services. The services most often requiring prior approval are durable medical equipment, skilled nursing facility stays, and Part B drugs.
But, each Advantage plan is different. If you have an Advantage plan, contact your plan provider to determine if or when prior authorization is necessary. Your plan will have forms you can download online.
Also, Advantage members may appeal to their plan’s denial. Yet, most don’t take advantage of this.
How Do I Get Prior Authorization for Medicare
Refer to your plan documents, including the drug formulary, to see if your treatment requires approval. This information should be on your plan’s website. The Medicare & You handbook also contains more information. Your provider is responsible for requesting permissions. Be sure to give them all the information they need for submission, ensuring it’s correct. Double-check your plan’s terms as well.
If your provider believes your treatment is medically necessary, they can contact your plan and request an exception if you get denied. The provider must support the request with a statement. Once approved, your plan pays without prior authorization.
How Long Does it Take to Get Prior Authorization?
It can take days to get prior authorization. Although, if you’re waiting for a drug, you should call your local pharmacy within a week. Sometimes, permission is either denied or delayed. If this happens, contact your insurance provider to ask why.
Does Medicare require prior authorization for MRI?
If the purpose of the MRI is to treat a medical issue, and all providers involved accept Medicare assignment, Part B would cover the inpatient procedure. An Advantage beneficiary might need prior authorization to visit a specialist such as a radiologist.
Does Medicare require prior authorization for a CT scan?
If your CT scan is medically necessary and the provider(s) accept(s) Medicare assignment, Part B will cover it. Again, you might need prior authorization to see an out-of-network doctor if you have an Advantage plan.
How do I get Medicare prior authorizations for a therapy regimen?
You’ll get prior authorization the same way, no matter the service. Your doctor will document medical necessity and send forms to either Medicare or your plan for approval.
Getting Help Understanding Prior Authorization
This information can seem overwhelming, and things are always changing. Our goal is to keep you informed to help you pick the best coverage for you. We can start helping by comparing rates in your area.
Call the number above to talk to an agent. Or fill out our online rate form to see costs.
About This Site
MedicareFAQ.com (hereinafter “the Site” or “this Site”) is an online resource for people seeking to learn more about their insurance options. Elite Insurance Partners LLC does not endorse any particular insurance plan, provider, or agent. Any information provided about any particular insurance plan, provider, or agent shall not be construed as an endorsement by Elite Insurance Partners LLC.
Copyright and Proprietary Rights Information
This website is owned and maintained by Elite Insurance Partners LLC. No content or images may be downloaded or reproduced without our prior and explicit consent.
While every effort is made to ensure the accuracy of the content of medicarefaq.com, we cannot be held accountable for typographical errors, errors of fact, or any other error or inconsistency found on this website. We hereby disclaim all liability from any damages resulting from the use of this website, or any services provided on any Elite Insurance Partners LLC website.
Links to Third Party Sites
This Site may contain links to sites that are controlled by third parties. These linked sites are not under the control of Elite Insurance Partners LLC, and Elite Insurance Partners LLC is not responsible for the contents of any linked site or any link contained in a linked site.
Information Collected by Elite Insurance Partners LLC
Elite Insurance Partners LLC uses this website to collect personally-identifiable information. When you use our service, you are authorizing the sharing of your inquiry and your personal information with Elite Insurance Partners LLC. The personal information we collect may include, but is not limited to:
These technologies help companies measure the effectiveness of ads, content, user experience and other marketing activities.
How Information Is Collected
We only collect your personally-identifiable information when you choose to share it with us. We will not collect any personally-identifiable information without your consent. The information you choose to share with us may be collected through this website, another website in the Elite Insurance Partners LLC network, or collected over the phone by one of Elite Insurance Partners LLC licensed insurance agents.
Cookies and other technologies, such as web beacons or tags, may be sent to visitors of this website. “Cookies” are text-only pieces of information that a website transfers to an individual’s hard drive or other web site-browsing equipment for record-keeping purposes. Cookies allow the website to remember important information that will make your use of the site more convenient. A cookie will typically contain the name of the domain from which the cookie has come, the “lifetime” of the cookie, and a randomly generated, unique number or other value. A “beacon,” “tag,” or “tracking pixel,” is a one pixel by one pixel image placed on a web asset or email. When your browser connects to a web page and the web page contains a web beacon image, your browser makes a request to the web server to download that image — and with this request, the server logs certain details like your IP address, the date and time, and more.
With cookies, web beacons and other technologies, the information collected and used is always anonymous and does not enable any third-party to identify you individually.
How Information Is Used & Opting-Out
By choosing to submit your personally-identifiable information to us, you are authorizing Elite Insurance Partners LLC to use this information for any purpose in our sole discretion. An Elite Insurance Partners LLC licensed agent may contact you by phone, email, mail, or other form of communication to fulfill your inquiry and provide you with other offers you may be interested in. You expressly consent to receive these communications whether you are on any Federal or state DNC (Do Not Call) and/or DNE (Do Not Email) list or registry.
Although it is our hope that you find this service valuable, if you would prefer not to participate, you can opt-out of this activity at any time by following the browser-specific instructions at the following link: https://www.usa.gov/optout-instructions
If you no longer wish to receive further communications from Elite Insurance Partners LLC, you may “opt-out” at any time and we will remove you from our mailing list within 10 days. You may opt-out of receiving emails by following the “Unsubscribe” link at the bottom of our emails, or by contacting us via the information below.
Elite Insurance Partners LLC 34125 Us Highway 19 North – Unit 200 Palm Harbor, FL 34684 firstname.lastname@example.org 1 (800) 845-2484
Changes to This Policy
This website is owned and operated by Elite Insurance Partners LLC.
Aetna Health and Life Insurance Company (An Aetna Company)
American Continental Insurance Company (An Aetna Company)
American Retirement Life Insurance Company (A Cigna Company)
Anthem Blue Cross Blue Shield
Blue Cross Blue Shield
Central States Indemnity (A Berkshire Hathaway Group Company)
Continental Life Insurance Company (An Aetna Company)
ForeThought Life Insurance
Gerber Life Insurance
Government Personnel Mutual
Individual Assurance Company
Loyal American Life Insurance Company (A Cigna Company)
Mutual of Omaha
New Era Life Insurance
Omaha Insurance Company (A Mutual of Omaha Company)
Philadelphia American Life Insurance
SilverScript (A CVS Caremark Company)
Standard Life and Casualty
Stonebridge Life Insurance (A TransAmerica Company)