January 18th 2024
By Ari Parker
Learn about Medicare prior authorization requirements, how to submit a prior authorization request, and the appeals process for a prior authorization denial.
In your experience with insurance, you may have seen prior authorization requirements for some services and treatments. Insurance carriers often require prior authorization to reduce their costs for unnecessary medical care.
Original Medicare doesn’t require prior authorization for Medicare-covered services and equipment. However, Medicare Advantage enrollees may need to get approval before receiving the services and equipment they need. In this post, we’ll dive more into the definition of prior authorization, requirements for prior authorization, and how to ensure you have it if you need prior authorization.
Medicare prior authorization isn’t necessary with Original Medicare.
Medicare Advantage plans often require prior authorization for services and equipment, especially less common or more expensive services
Part D (prescription drug) plans may require prior authorization for expensive drugs and misused drugs.
You can get prior authorization for services by contacting your insurance and following the necessary steps.
You can appeal a prior authorization denial.
Medicare prior authorization is when you have to get approval from Medicare or your insurance carrier before you can get a service, medication, or piece of equipment. For instance, you may need to get prior authorization from your Medicare Advantage plan carrier before receiving orthopedic surgery to ensure proper coverage. If your insurance carrier rejects your application for prior authorization, you can appeal the decision, but will otherwise be responsible for the full cost of the service.
Medicare prior authorization practices exist for four key reasons. First, they protect patients, ensuring that you’re receiving the correct services, medical equipment, and prescriptions. Second, they help to reduce the costs incurred by the government and Medicare insurance carriers by cutting back the number of unnecessary services, equipment, and prescriptions.
Third, by reducing unnecessary care, those who need services and treatments can receive quicker access. Finally, prior authorization can give patients peace of mind because you’ll be sure that your insurance will cover your procedure even if you have to make a claim.
Unfortunately, prior authorization requirements and denials have become all too common among Medicare Advantage plans. Frequent prior authorization requirements are one of the most complained about Medicare Advantage Nightmares because the practice delays or prevents access to care—even when it’s necessary.
Medicare prior authorization practices depend on the type of Medicare coverage you have. Original Medicare plans don’t require prior authorization, but Medicare Advantage plans often do.
Part D prescription drug plans can also require prior authorization, especially for expensive medications, drugs that are abused, or drugs that are commonly used for reasons other than their FDA-approved purpose (like Ozempic).
You won’t need prior authorization for emergency services since there wouldn’t be enough time to approve the service.
Original Medicare will only ever require prior authorization for three kinds of treatments and services:
Outpatient services (usually dermatology)
Durable medical equipment (medically necessary tools you may need)
Medicare Advantage plans, on the other hand, often need prior authorization for many treatments and services, including:
Diagnostic lab work and tests
Home health services
Short-term inpatient hospital stays
Outpatient substance abuse services
Durable medical equipment
You can learn more about Medicare Advantage plan services that often require prior authorization here.
Your Part D plan may require prior authorization for the following medications:
Drugs with high risks and side effects
Drugs that can be misused, abused, or cause addition
Drugs that could be used for cosmetic purposes rather than their intended purposes
Drugs that are expensive
If you have Original Medicare, you won’t need prior authorization for surgery. This excludes any surgeries that aren’t covered by Medicare (like cosmetic surgery). Medicare Advantage plans may require prior authorization for surgery—especially expensive surgeries. If you’re a Medicare Advantage enrollee, make sure to connect with your doctor’s billing department to sort out prior authorization and determine what you’ll owe out of pocket for your surgery.
Original Medicare doesn’t cover prescription drugs, and each prescription drug plan has different prior authorization requirements. If you need a surgery that requires painkillers or other prescriptions afterward, you may need your provider to get prior authorization through your plan.
The best way to see if you need prior authorization for a service or medication is to check with your plan provider or your doctor’s billing department. Your doctor’s billing department will also help you get prior authorization.
For some prescription medications, your healthcare provider will contact your plan to explain that a drug is medically necessary. For medical services, you can start the prior authorization process by contacting your insurance company and following the insurer’s steps. Your doctor’s billing department can also help with this.
If you enrolled in Medicare coverage using a Chapter Medicare Advisor, our team of Advocates will help you apply for prior authorization and appeal any prior authorization request denials.
Prior authorizations usually take 3-5 days. In more complex situations, requests can take longer to process, which can pose challenges for people with more immediate needs.
Keep in mind: If you are denied prior authorization, you can always appeal it. It’s always worth an appeal if you get rejected. In 2021, only 11% of rejected prior authorizations were appealed. Of those that were appealed, however, 82% were approved prior authorization.
Needing prior authorization can be a burden for Medicare beneficiaries. It can be challenging to understand which services and treatments require prior authorization because every Medicare Advantage plan is different. Requesting prior authorization and appealing denials also takes time, which delays access to care. Finally, some Medicare beneficiaries are denied coverage for services that they need! Doctors are becoming increasingly frustrated with Medicare prior authorizations because they want to ensure their patients get the care they need in a timely manner.
Frequent prior authorization requirements are part of why many people say Medicare Advantage plans are considered worse than Original Medicare plans. The easiest way to avoid prior authorization requirements is to stay on Original Medicare. We’d also recommend getting a Medicare Supplement plan to help cover the 20% of costs that Original Medicare doesn’t cover. In some cases, this isn’t the right combination of coverage for Medicare beneficiaries. Some people prefer Medicare Advantage plans for the extra benefits they provide, and others cannot afford a Medicare Supplement plan premium.
If you want to enroll in Medicare Advantage, it’s good to know that different carriers have different prior authorization policies. Consider carriers who are less likely to require prior authorization requests.
If you’re having doubts about your plan or want to see what other options you have, our team of Medicare insurance agents is here to help! Get one-on-one support today from an Advisor who can break down Medicare, help you understand prior authorization requirements, and find a plan that best suits your needs. Call 855-900-2427 or schedule a chat today to get started.
