Medicare Advantage Prior Authorization: What It Is and How to Navigate It
Prior authorization is one of the most frustrating aspects of Medicare Advantage -- and one of the most important to understand. Here is how prior authorization works and what to do when it is denied.
Medicare Advantage Prior Authorization: What It Is and How to Navigate It
Prior authorization -- the requirement that your insurance plan approve certain services, medications, or procedures before you receive them -- is one of the most significant differences between Medicare Advantage and Original Medicare. Understanding how it works, and what to do when it is denied, is essential for MA enrollees.
What Is Prior Authorization?
Prior authorization (PA) is a process by which your Medicare Advantage plan reviews and approves (or denies) coverage for certain services before they are provided. The plan evaluates whether the requested service is medically necessary and covered under your plan.
Original Medicare does not require prior authorization for most services -- your doctor orders a service and Medicare pays. Medicare Advantage plans, by contrast, can require prior authorization for a wide range of services.
What Commonly Requires Prior Authorization
Requirements vary by plan, but common services requiring PA include:
- Inpatient hospital admissions (non-emergency)
- Skilled nursing facility admissions
- Inpatient rehabilitation
- Home health services
- Durable medical equipment (power wheelchairs, CPAP, home oxygen)
- Specialty medications
- Certain imaging (MRI, CT, PET scans)
- Outpatient surgery
- Specialist referrals (in HMO plans)
- Physical, occupational, and speech therapy (beyond initial visits)
How to Get Prior Authorization
- Your doctor initiates the request -- the provider's office submits a PA request to your plan with clinical documentation supporting medical necessity
- The plan reviews the request -- typically within 3-5 business days for standard requests; 72 hours for urgent requests
- Approval or denial -- you and your doctor receive written notification
Tips for smooth PA:
- Ask your doctor's office to submit PA requests well in advance of scheduled procedures
- Ensure the PA request includes complete clinical documentation
- Confirm the PA is approved before the service is provided
When Prior Authorization Is Denied
If your PA request is denied, you have the right to appeal. The Medicare Advantage appeals process has multiple levels:
Level 1 -- Organization Determination: The initial PA decision. If denied, you can request reconsideration.
Level 2 -- Reconsideration: The plan reviews the denial. Must be completed within 30 days (standard) or 72 hours (expedited). If upheld, the case goes to an independent review entity.
Level 3 -- Independent Review Entity (IRE): An independent organization reviews the denial. This is a critical level -- IRE decisions are binding on the plan.
Levels 4-5: Administrative Law Judge hearing, Medicare Appeals Council, Federal court.
Expedited Appeals
If waiting for a standard appeal would seriously jeopardize your health, you can request an expedited appeal. The plan must respond within 72 hours.
When to request expedited review: Urgent medical situations -- imminent hospital discharge, denial of urgent care, situations where delay could cause serious harm.
Your Doctor's Role in Appeals
Your doctor's support is essential for a successful appeal. Ask your doctor to:
- Write a letter of medical necessity explaining why the requested service is appropriate
- Cite relevant clinical guidelines and peer-reviewed literature
- Document why alternatives are not appropriate for your specific situation
CMS Oversight of Prior Authorization
CMS has increased scrutiny of MA prior authorization practices in recent years, finding that many denials are inappropriate. If you believe your plan is systematically denying medically necessary care, you can file a complaint with CMS or your State Health Insurance Assistance Program (SHINE in Florida).
We do not offer every plan available in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
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About the Author
William Gray
Independent Medicare BrokerUS Air Force Veteran · Florida Medicare Specialist
William Gray is an independent Medicare insurance broker based in Daytona Beach and Palm Coast, FL. A US Air Force veteran (A-10 crew chief, Germany), he spent years in corporate insurance before going independent to serve Florida seniors directly. He has helped more than 1,000 clients across Northeast Florida compare Medicare Advantage, Medigap, and Part D plans — always at no cost to the client.
