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Medicare Prior Authorization Explained

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.

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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 Medicare Advantage and Medicare 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

Medicare 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.

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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.

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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.

Jagger Esch

Jagger Esch

Medicare Educator
Jagger Esch is the Medicare Educator for MedicareFAQ and the founder, president, and CEO of Elite Insurance Partners and MedicareFAQ.com. Since the inception of his first company in 2012, he has been dedicated to helping those eligible for Medicare by providing them with resources to educate themselves on all their Medicare options. He is featured in many publications as well as writes regularly for other expert columns regarding Medicare.

28 thoughts on "Medicare Prior Authorization Explained"

  1. I am 84 and have had Medicare A & B since I’m 65, but I never signed up for Part D. If I switch to Medicare Advantage plan, can I get Par D?

    1. You can either enroll in a stand alone Medicare Part D plan or if you wish to enroll in a Medicare Advantage Prescription Drug Plan, you can do that as well. However, if you switch to Medicare Advantage, it is important to ensure your doctors and hospitals will be covered by the plan.

  2. I’m looking to see if Medicare needs a prior authorization for a patient to have Bariatric Surgery. Do I need to submit all required documentation a head of scheduling surgery? Is there a pre-determination required? Please advise. Thank you.

    1. Hello Gina, Medicare does require a prior authorization for bariatric surgery. You will need to submit your documentation ahead of the surgery.

  3. Hello. I have original Medicare with a medigap supplement. My primary care physician had me do an ultrasound examination of my heart with no issues found. Now, only 2 months later, my cardiologist wants me to have the same procedure performed. Will my original Medicare pay for this again?

    1. Joe, as long as the new ultrasound is deemed medically necessary, there should not be an issue with Medicare paying the claim. However, I would reach out to your physician as well to verify the coverage.

  4. hello Jagger, I was diagnosed with esophgeal cancer dec 15th 2021 during a routine upper GI scope.( I have GERD) I turned 65 years old last july and got set up on medicare with A&B and a AARP united health supplement plan and wellcare prescription plan last year. The cancer was first noted as very small but after going to more CT scans, PET scans and a endoscopic procedure in which it was determined the tumor was too large to remove. Now I am looking at chemo and radiation therapy followed by surgery to remove part of stomach and esophagus. being new to medicare and having this now become much more serious can you give me any advise on what to do to make sure I am getting all of the benefits I am entitles to.

    1. Hi Mark, I am sorry to hear about your diagnosis. After reading your comment it seems to me that you are enrolled in all the right plans and are receiving the benefits you are entitled to.

    1. Kady, Original Medicare typically does not need prior authorization if the sleep study has been deemed medically necessary by your doctor.

  5. Good morning. I have medicate and supplemental (Anthem) insurance. I have a routine colonscopy scheduled this week. Is pre-authorization from medicare required ? Does the doctor’s office or the patient contact medicare for pre-authorization ?

    1. Hi Irene – Part B will cover your CT scan if it is medically necessary, so you wouldn’t need prior authorization. If you have an Advantage plan, you may need prior authorization to visit a doctor outside of your network.

  6. I AM COMING OFF HOSPICE THEY FURNISH MY OXYGEN EQUIP,ENT WHICH THEY NEED TO PICK UP I AM HAVING A PROBLEM GETTING NEW RQUIPMENT BECAUSE MEDICARE WILL NOT PAY WHY

    1. Hi Joyce! If you have Original Medicare Part A & Part B only, no. If you have a Medicare Advantage plan, it’s up to the carrier if they require prior authorization.

  7. We just received a bill for $160,000 for a one-day procedure that was pre-authorized. Our insurance company says that Medicare won’t pay it, so the whole bill is on us even though we got pre-authorization. What is the use of pre-authorization if the bill isn’t going to be at least partially paid by Medicare?

    1. Hi Virginia. This sounds like a billing error. Your best option is to do a three-way call between the billing department and Medicare to have this resolved ASAP.

  8. My husband had an AVM 20 years ago. Ten years later a large cyst developed at site which required surgery. He has had small non-verbal seizures since then until 2 weeks ago. The last 2 caused confusion for an hour. It has been 11 days since doctor ordered MRI but we are waiting on prior authorization. Should it take that long?

    1. Hi Marilyn! Unfortunately, this is one of the many downfalls of Medicare Advantage plans. You should be able to log into your online portal either through the Advantage carrier or Medicare to see the status of your prior authorization. But yes, it can take this long depending on the carrier you enrolled with.

  9. I am inquiring if medicare is primary and patient has medicare supp as secondary and it follows medicare guidelines, is the medicare authorization used for the supplement coverage too or does a separate auth have to be obtained?

    1. Hi Maria! A Medicare Supplement policy will always cover anything Medicare overs. If Medicare approved the service or procedure and required a prior authorization form, the Medigap plan will NOT require an additional prior authorization form. I hope this helps!

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

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