Medicare Prior Authorization - Pre-Approval For Your Health Needs

By: Meredith Miller
Published: Friday, September 07 2018
Last Updated: 4 years ago

Reaching that Medicare eligibility age is a milestone many people look forward to. Medicare coverage is comprehensive and generally affordable. Still, any new insurance plan comes with a learning curve, and you are bound to experience a headache or two, along the way.

If you’ve had experience with commercial insurance plans prior to your Medicare enrollment, you may already be familiar with a prior authorization form. Pre-authorization is a fairly common practice in the health insurance industry, but now you may wonder if Medicare prior authorization exists and what the process is.

What Is Medicare Prior Authorization?

A prior authorization form is required when healthcare providers must get pre-approval from a patient’s insurance company to provide a patient with a specific service or treatment. Medicare prior authorization works the same as with other insurance companies. Your doctor or provider submits a prior authorization form to the Centers for Medicare & Medicaid Services (CMS). When your provider receives approval, they can proceed with your treatment.

Is Prior Authorization Required?

Prior authorization is not required for most services under traditional Medicare. There are few situations where a prior authorization form may be required for Medicare beneficiaries. This includes certain supplies furnished to you that are known as durable medical equipment. CMS also has a limited set of physician services that require pre-approval. These situations are rare and your provider will notify you if prior authorization is required.

If you have a Medicare Advantage plan or Medicare Part D for prescription coverage, then you are more likely to encounter the need for prior authorization. These plans are all administered by commercial insurance companies on behalf of Medicare, and, as a result, often require the use of prior authorization as a cost-saving measure.

How Long Does Prior Authorization Take?

The time a Medicare prior authorization takes varies depending on the specifics of your situation. Depending on whether you are requesting an authorization from Original Medicare, a Medicare Advantage provider, or a Part D provider, the process can be as quick as the same day or take several days. In most cases, expect to wait at least 1 to 3 days for a prior authorization to be processed.

What Happens If Your Physician Can’t Get Authorization?

During the authorization process, you should stay in contact with your provider and make sure they are following up with Medicare. This will ensure your request isn’t lost or forgotten. If your prior authorization is denied, it typically means Medicare will not pay for the requested services. Your provider has the option if they believe the services or supplies are necessary, to file an appeal with Medicare. If you lose your appeal, you may consider paying for the services yourself.

Prior Authorization Specialists

If you are going through the Medicare prior authorization process, you may want to get to know your provider’s prior authorization specialist. Most providers have dedicated positions for prior authorizations. The prior authorization specialist can help walk you through the process and keep you updated on the progress of your request. They can also help you file an appeal if that becomes necessary.

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Nothing is worse than spending days painstakingly waiting for authorization only to get denied benefits from your Medicare. Luckily, there is a way to make sure that doesn’t happen.

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