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 rarely requires prior authorization for Medicare-covered services and equipment. Medicare beneficiaries with Medicare Advantage plans, however, will often 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. 

Key takeaways:

  • Medicare Advantage plans often require prior authorization for services and equipment, especially less common or more expensive services

  • Original Medicare rarely requires prior authorization.

  • Part D (prescription drug) plans also 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.

What is prior authorization in 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 covered by insurance. 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. 

Why do you need prior authorization?

Prior authorizations 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. 

Does Medicare require prior authorization?

Whether or not you need prior authorization for Medicare depends largely on the plan that you have. While Original Medicare plans rarely require prior authorization, Medicare Advantage plans require prior authorization more frequently. 

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). 

Which procedures and medications does Medicare require prior authorization for?

You typically 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)

  • Non-emergency ambulance services

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

Does medicare require prior authorization for surgery?

If you have Original Medicare (Part A and Part B), it’s highly unlikely that you’ll need prior authorization for surgery. Medicare Advantage, however, requires prior authorization for outpatient services like surgery much more frequently.

Original Medicare doesn’t cover prescription drugs, and each prescription drug plan has different prior authorization requirements. If you need a surgery that requires strong drugs afterward, you may need your provider to get prior authorization through your plan.  

How do I know if I need prior authorization?

The best way to see if you need prior authorization for a service or medication is to check with your plan provider. You should be able to find information on pre-approved services and drugs in health insurance documents. It’s a good idea to always communicate with your medical provider’s billing department before a medical procedure to know what steps you need to take for proper coverage and how much you can expect to pay out of pocket. 

How do I get prior authorization from Medicare?

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.

How long does it take to get approval 

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.

Challenges of prior authorization for Medicare

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! 

Frequent prior authorization requirements are part of why Medicare Advantage plans are considered worse than Original Medicare plans. 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.

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