Medicare Prior Authorization: Procedures and Conditions to Follow

Medicare approval process and necessary criteria

In the world of healthcare, prior authorization plays a crucial role in ensuring compliance with Medicare rules and regulations, particularly in relation to billing. This process helps reduce fraud and abuse of the Medicare system.

For those enrolled in Medicare Advantage (Part C) plans or Part D prescription drug plans, prior authorization is often a requirement for certain services or medications. If a person's Medicare Advantage plan does not preapprove a given service, they will have to bear the full cost. In contrast, people with Original Medicare (parts A and B) typically will not need prior authorization to receive care.

However, it's important to note that Medicare Advantage plans are administered by private companies, unlike Original Medicare, which is managed by the federal government. As a result, Medicare Advantage plans often require members to get preapproval before receiving care.

Services such as hospital visits, specialist appointments, and out-of-state care are all preapproved with Original Medicare. However, some hospital outpatient department procedures require prior authorization, including blepharoplasty, botulinum toxin (Botox) injections, panniculectomy, rhinoplasty, vein ablation, and more.

Certain pieces of durable medical equipment, like power wheelchairs, also require prior authorization to receive coverage under Part B. Prior authorization is a process for requesting coverage for a medical service, drug, or piece of equipment with Medicare.

The prior authorization process for Medicare includes an appeals process that allows people to challenge coverage decisions they feel were made in error. If a person's Medicare plan requires prior authorization, their doctor will typically take responsibility for submitting the request. Certain forms may need to be completed beforehand, asking for personal details and information about a person's health condition and medical history.

The Centers for Medicare & Medicaid Services (CMS) make decisions on requests for prior authorization in 7 calendar days (regular requests), and 2 business days for expedited requests (by 2025). Prior authorization can help ensure that a given drug or service is medically necessary and appropriate, as well as aligned with established clinical guidelines.

Lastly, it's worth mentioning that the prioritization procedure for Medicare Advantage involves evaluating eligibility, selecting a plan that meets the beneficiary's needs, and enrolling during specified enrollment periods. Priority is given to individuals based on criteria such as special needs, low income, and dual eligibility.

By understanding the prior authorization process, Medicare beneficiaries can make informed decisions about their healthcare and ensure they are receiving the care they need while adhering to Medicare rules and regulations.