Medicare Prior Authorization Explained

Last Updated on November 17, 2020 by Lindsay Engle

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.

Also, CMS has added specific cosmetic procedures to the list of outpatient care. The goal is to prioritize medically necessary procedures.

Medicare Part D Prior Authorization

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.

FAQs

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.

2 Comments

Kathy Aloisio says:

October 9, 2020 at 12:25 pm

Lindsay I work in the health care field and come across unique situations. Can I reach out to you via email for questions?

- Lindsay Engle says:
  
  October 12, 2020 at 9:23 am
  
  Of course! You can find my email address here.