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Does Medicare Require Prior Authorization?

When caring for your health, navigating the complex landscape of Medicare can often be challenging. What does my plan cover? What do I need to do to have my treatment covered? 

One crucial aspect to consider is prior authorization, which determines whether your plan will cover specific procedures. It can be frustrating for both healthcare providers and patients to navigate.

In this blog post, we will explore the concept of prior authorization for Original Medicare and Medicare Advantage plans, discuss the procedures that typically require it, and shed light on Medicare’s process. 

What Does Prior Authorization Mean?

Prior authorization is a process in which Medicare makes sure healthcare providers get permission before doing specific procedures or treatments. It helps make sure the treatment is necessary and the right choice. 

Medicare looks at your treatment or procedure details and will approve or deny your request. 

Your plan may use different terminology like “pre-certification” or “pre-approval.” 

Medicare and Prior Authorization

What does prior authorization look like for the different parts of Medicare? 

Medicare Part A

Prior authorization is typically not required for treatment under Medicare Part A. It may apply to some prosthetics. 

Medicare Part B

In some instances, Medicare will require prior authorization for medication administered in an outpatient setting. As well, some procedures require prior approval. 

Medicare Part D

Some medications require prior authorization before you can receive your prescription. Prior approval is necessary because Medicare will cover a specific medication for certain conditions and not others. 

Medicare Supplements (Medigap)

Medigap plans do not have issues with prior authorization because the plans do not have the authority to deny claims. For example, on Plan G, as long as the claim is Medicare approved, the Medigap company has to pay the claim. They do not have the option not to!

Medicare Advantage

If you have a Medicare Advantage plan and need to see a specialist not in your plan’s network, you may have to get permission beforehand. This is called prior authorization. It’s important to know that your Advantage plan won’t pay for any of the costs if Medicare doesn’t approve your request. You would have to pay the total fee on your own.

Each Medicare Advantage plan is different, so you must review your plan for what does and does not require prior authorization. Over 99% of those enrolled in Medicare Advantage plans require prior approval for some services or treatments. 

Commonly Asked Questions About Prior Authorization and Specific Procedures

Doctor showing x-ray scans of head to senior female patient

Do I need prior authorization before an MRI? 

If you need an MRI to treat a medical problem, and the healthcare providers accept Medicare assignment, then Medicare Part B will help cover the cost of the procedure. However, if you have a Medicare Advantage plan, you might need prior authorization to see a specialist like a radiologist.

Do I need prior authorization for a CAT scan? 

Again, if your doctor deems it medically necessary, you do not need prior authorization under Medicare Part B. However, you may require prior approval under your Medicare Advantage plan. 

This applies to other medical imaging procedures, like a PET scan or echocardiogram. 

Do I need prior authorization before starting physical therapy? 

Virtually every Medicare Advantage plan requires prior authorization for physical therapy. 

What is the process for procedures that require prior authorization? 

The process for procedures that need prior authorization has a few steps. Usually, your healthcare provider starts the request for you. They send important documents like medical records, test results, and details about the treatment you need to Medicare for review. Medicare checks if the procedure meets its rules for coverage. 

Medicare or your Medicare Advantage plan will send you a letter outlining their decision. If your request is denied, you have the option to appeal their decision. 

How much time does Medicare usually take to approve a procedure?

Does Medicare Require Prior Authorization - Application signed, fountain pen and stamp approved, close up shot.

The timeline will vary, depending on your plan and many other factors. You will typically receive a response within 5-10 days, although it can take up to 30 days. 

Why would a prior authorization request be denied? 

Your plan may fully or partially deny your claim for prior authorization. There are several reasons why your request may be denied. It may be that documentation needed to be included or that the treatment was deemed medically necessary. Sometimes, your submission may be rejected until you try another treatment first. 

It also may be that it was wrongfully denied. An initial decision that is appealed will often result in a favorable outcome. 

Legislative updates around prior authorization policies

Over the past few years, there has been an uptick in prior authorization requests being denied or causing delays in necessary treatments. 

To that end, some legislation is being introduced to resolve this issue. For example, Louisiana, Michigan, and Texas passed prior authorization laws where some doctors and hospitals are exempt from prior authorization because their requests are almost always approved. Several other states are considering similar legislation. 

Moreover, in April, new rules were introduced to make the process of prior authorization simpler and more efficient. These rules were designed to ensure that beneficiaries continue receiving their medical care even if they switch from one Medicare Advantage plan to another or from traditional Medicare to Medicare Advantage. The aim is to prevent interruptions in healthcare services for beneficiaries due to changes in their Medicare coverage.

Navigating Medicare with The Medicare Family

Understanding the nuances of Medicare and its various requirements can be overwhelming, especially if you are getting ready to enroll. That’s where The Medicare Family comes in. With our expertise and dedication, we can provide you with personalized guidance and support throughout your Medicare journey. 

From helping you navigate prior authorization requirements to finding the most suitable coverage options, The Medicare Family is here to empower you to make informed decisions about your healthcare. Contact us to learn more today!

Sylvia Gordon, aka Medicare Mama®, is an expert on all things Medicare and Social Security. She is the 2nd Generation here at The Medicare Family and has served on the advisory boards of major insurance companies like UnitedHealthcare®, Cigna, and Anthem. In her free time, she can be found taking care of her animals (dogs, goats, peacocks, chickens), and reading a good book. Learn More.

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