Does Medicare Require Prior Authorization: Medicare FAQs

Medicare (US health insurance program for people 65 or older) often requires prior authorization to review your request for a specific medical treatment or medication before approval. Medicare offers different health plans to its users. Each plan has criteria allowing patients to avail of certain Medicaid services. 

Thus, getting prior approval from the US state health insurer for your medical necessity or medication is essential. Otherwise, you’ll need to pay the total cost yourself.

According to the latest statistics, Medicare has more than 60 million registered US citizens in its health plans. Many US state insurer-enrolled members will require prior authorization for a specific medical treatment or medication.

As Medicare covers several medical facilities in different plans, it may become confusing whether you need prior approval for your medical necessities.

This article will answer many of your questions related to Medicare prior authorization.

What Does Medicare Prior Authorization Mean?

Medicare prior authorization refers to the process where a Medicare-enrolled member seeks approval from Medicare to get a particular medication or medical necessity.

For instance, you went to the doctor after facing an injury. The healthcare provider suggests a specific medical treatment. Before he starts treating you, he needs to submit a prior authorization request to Medicare seeking approval.

However, if your healthcare provider fails to submit a request, your insurer won’t pay for your medical costs, and you’ll need to pay the entire bill on your own.

Why Does Medicare Often Require Prior Authorization Requests?

There are many reasons why Medicare requires prior authorization requests for a medical facility. One of the main reasons is to prioritize medically obligatory care. Prior authorization helps insurers review the request to ensure the prescribed treatment or medication is necessary before they approve it.

Due to that, Medicare (similar to private insurance companies) also demands its users to submit a prior approval request before taking any medical facility.

Prior authorization ensures that only the patients who need urgent care get it. It also helps in keeping the Medicare expenses down. Prior authorization ensures you get approval from your healthcare insurance provider before obtaining a specific medical necessity. It saves you from the risk of paying for your entire bill if your request gets denied on late submission.

How Medicare Prior Authorization Functions?

The Medicare prior authorization follows a similar process to that of a private health insurance company. Here are some of the critical steps of how Medicare prior authorization runs.

For instance, you visit a physician for medical care. The physician prescribed a specific medication or medical treatment to cure your illness. However, before starting your medical care, he must get approval from Medicare to ensure your medical expenses are covered within your health plan.

Your healthcare provider submits a request form and all necessary information to your insurer (Medicare). The health insurance company reviews your prior authorization request for a specific medical treatment or medication. Based on the clinical data and information your healthcare provider has forwarded to Medicare, they revert with their decision whether to approve or refuse the request.

However, if Medicare finds your prior authorization request qualifies the health plan criteria, they’ll approve your request for a particular medication or medical necessity. Conversely, your insurance provider may reject your request if it meets the health plan requirements. You may directly request Medicare or ask your healthcare provider to talk to review their decision if they deny approving your prior authorization request.

What Type Of Situations Need Medicare Prior Authorization?

The conditions for submitting a Medicare prior authorization can vary based on your health plan. However, some situations likely require prior approval for a specific medical treatment or medication. Below are those medical conditions.

I was visiting a specialist.

I am obtaining non-emergency medical care.

Seeing an external (out-of-network) doctor.

Getting certain prescription drugs.

How Do I Know If I Need Medicare Prior Authorization?

The best way to know whether you require Medicare prior authorization is to contact your healthcare insurer. However, when you sign up for a Medicare healthcare plan, you get a document that contains medical services for which you don’t require prior approval. You can visit that document to see if your prescribed medical treatment or medication falls within the list. Also, you can call your healthcare insurance provider’s website to find out whether you need to submit a prior authorization request.

If you are a Medicare Part A or Part B health plan holder, you’ll likely not require prior authorization for many medical services that are pre-approved beforehand. However, you may still re-check with your healthcare insurer to ensure all medical bills get covered within your health plan. Durable hospital equipment and prosthetics are some medical services for which you’ll need prior approval.

Medicare Part C and D frequently ask for Medicare prior authorization. Medicare Part C (also known as Medicare Advantage) demands your healthcare provider get approval before they provide you with any specific medical treatment. Similarly, Medicare Part D (for pharmaceuticals) requires you to obtain prior authorization from Medicare to get a prescription drug.

Medicare Advantage Prior Authorization

To obtain medical care from a specialist, out-of-network healthcare provider, or emergency care provider, you must submit a prior authorization request as a Medicare Advantage (MA) plan holder. It covers most medical facilities; however, getting prior approval is essential to avoid any inconvenience later. If Medicare rejects your request, your MA plan won’t pay your bills, and you’ll have to clear your bills independently.

Your healthcare provider doesn’t need prior authorization for general medical services as your Medicare Advantage plan comes with several last-approved medical services. However, you must submit a prior authorization request for specific medical necessities like a skilled nursing facility or durable medical equipment.

Every health plan offers different services. Thus, knowing what type of medical facilities your health insurance plan can cover is essential before taking any medical treatment or medication.

Contact your healthcare insurer to get to understand your health plan. A better understanding of your health plan can let you decide whether to seek a prior authorization request for a specific medication or medical necessity. 

Medicare Advantage Plans Decoding the Prior Authorization Process

Delving into healthcare, Medicare Advantage plans are a pivotal choice for individuals 65 and older. These plans offer comprehensive coverage, making them a popular option for many. Grasping the nuances of Medicare Advantage plans is crucial, particularly regarding the prior authorization process.

Medicare Advantage plans have established specific prior authorization practices to streamline the approval of medical treatments and prescriptions. This process ensures enrollees receive the necessary care while maintaining the integrity of the healthcare system.

Successfully navigating the prior authorization determinations within Medicare Advantage plans involves active engagement with healthcare providers, emphasizing the medical necessity of prescribed treatments. By comprehending the intricacies of the prior authorization process and adhering to established practices, beneficiaries can confidently embrace the benefits of their Medicare Advantage plans.