How Medicare Prior Authorization Works
Medicare prior authorization rules differ from commercial insurance. Traditional Medicare (Part A and B) prior authorization is limited to specific services defined by CMS. Medicare Advantage plans (Part C) often have more extensive prior authorization requirements set by individual insurance companies.
For Traditional Medicare, prior authorization is required for certain high-cost procedures and some services. Providers can use the Medicare Prior Authorization System (MPASS) to request authorization. Urgent prior authorizations are processed within 72 hours.
Medicare Services Requiring Prior Authorization
Services requiring prior authorization include: certain imaging procedures (some advanced imaging), certain surgeries and procedures, home health services, skilled nursing facility stays, and specific DME (durable medical equipment). The specific services change periodically as CMS updates policies.
Check CMS.gov or your provider's office to determine if your planned procedure requires prior authorization.
Medicare Advantage Prior Authorization
Medicare Advantage (Part C) plans set their own prior authorization requirements within limits. These plans typically require prior authorization for more services than traditional Medicare. Review your specific plan's documentation for requirements.
If Medicare Advantage denies coverage, you have appeal rights including reconsideration, appeal, and external review. Request reconsideration if you believe the denial was incorrect.
Recent Medicare Prior Authorization Changes
CMS has simplified some prior authorization processes and expanded electronic authorization submission. Check CMS.gov for recent changes. Proposed federal legislation would further streamline Medicare prior authorization by implementing credentialing-based approaches for high-performing providers.
Appealing Medicare Denials
Traditional Medicare denials can be appealed through the Medicare appeal process: redetermination (within 120 days), reconsideration (if redetermination is appealed), and administrative law judge hearing. Each level has specific timelines and requirements. Contact your local Medicare office or your healthcare provider's office for assistance with Medicare appeals.