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Medicare Prior Authorization

What Is Medicare Prior Authorization
08/31/2022
  • Medicare with Melissa

Medicare Prior Authorization is a cost-saving measure that requires your doctor or other health care provider to get approval from Medicare before you receive certain types of care. In some cases, prior authorization can even help you avoid costly mistakes, such as receiving duplicate tests or procedures.

If you have a Medicare Advantage Plan, your plan may use different names such as, “pre-certification,” “pre-authorization,” or “preapproval.” Your doctor or other health care provider will need to submit a request to the plan for approval before you receive certain services or supplies.

What is Medicare prior authorization?

Prior authorization is a way for your doctor or other health care provider to get approval from Medicare before providing certain services or medical supplies to you. They do this by submitting a request for to the company that administers your Medicare plan.

This will ensure that the services or supplies are covered by Medicare and that you’ll only have to pay your Medicare plan’s co-insurance, deductible, or co-payment amount. This process may also help control costs by making sure that only medically necessary services and supplies are provided.

What procedures does Medicare require prior authorization?

There are certain procedures that Medicare requires prior authorization to be covered. These procedures include, but are not limited to, hospital stays, surgeries, and certain tests and procedures. Your doctor or other health care provider will need to submit a request to Medicare, or your Medicare Advantage plan before you can receive coverage for these services.

In some cases, your prescription medications may also require a similar process.

Does Medicare Part B require prior authorization?

Medicare Part B does not require prior approval for most medical services and supplies. However, there are a few exceptions where Part B may need pre-authorization from your doctor or other health care provider. These include power wheelchairs, home health services, outpatient mental health services, clinical research studies, and durable medical equipment (DME).

To get Part B pre-authorization, you or your doctor must contact the Medicare plan directly. Each plan has its own rules about what services and supplies require pre-authorization. If you receive a service or supply that requires pre-authorization, and you don’t have the authorization, Medicare may not pay for the service or supply. Sometimes you may have to pay for the service or supply yourself.

It’s important to remember that not all Medicare plans work the same. For example, Medicare Advantage plans may have different requirements and pre-authorizations than Original Medicare with a Medicare Supplement Plan (Medigap Plan).

What is the prior authorization process?

If your doctor or other health care provider thinks you need a service that requires prior authorization, they will contact Medicare on your behalf to request approval. Medicare will then review the request and decide about whether to approve the service. If Medicare approves the service, they will send you a letter letting you know that you can go ahead and get the service. If Medicare denies the service, they will send you a letter explaining why. You have the right to appeal any decision made by Medicare about your care. 

If you have a Medicare Advantage plan, this authorization is all controlled within the plan itself, not Medicare.

How long does it take for Medicare to approve a procedure?

It can take up to 30 days for Medicare to approve a procedure. In some cases, however, approval may be granted sooner. If you have questions about the status of your application, you can contact Medicare directly.

Does Medicare require prior authorization for surgery?

No, Medicare does not require prior authorization for surgery. However, your doctor or other health care provider may need to get approval from Medicare before Medicare will pay for some types of surgeries. In some cases, the location of the procedure may also be subject to this process.

Does Medicare require prior authorization for MRI?

No, Medicare does not require pre-approval for MRI. If the MRI is medically necessary and your doctor accepts Medicare, you should be able to get the MRI without having to get pre-authorization.

Does Medicare require prior authorization for a CT scan?

No, Medicare does not require pre-authorization for CT scan. Medicare Part B covers CT scan if it’s medically necessary and your doctor accepts Medicare. However, some Medicare Advantage Plans may require pre-authorization for CT scan. You should check with your plan to see if this is requirement before services are performed.

Does Medicare require prior authorization for cataract surgery?

This depends on the specific circumstances surrounding your cataract surgery. In general, Medicare will not require prior authorization for cataract surgery that is considered medically necessary. However, there are some cases in which Medicare may require pre-approval for cataract surgery, such as when the surgery is being performed for cosmetic reasons. If you have any questions about whether your case will require pre-authorization, you should contact your Medicare provider for more information.

Does Medicare require prior authorization for physical therapy?

No, Medicare does not require prior authorization for physical therapy. You may be required to get a referral from your doctor, but you do not need to get pre-authorization from Medicare.

Get Help With Medicare Prior Authorization

The prior authorization process for Medicare can be a lengthy and complicated one. However, it is important to remember that this process is in place to ensure that patients receive the care they need in a timely and effective manner. By understanding the steps involved in the process, patients can be better prepared to navigate through the process and get the care they need.

For more information about prior authorization or to discuss any other questions you might have, please call 866-633-4427 to speak with a Senior HealthCare Solutions licensed agent today.

Meet Melissa MacCalla

Medicare is not simple and can be hard, frustrating, and downright confusing for most. I love when I get someone on the phone and I am given the opportunity to explain the difference in plans to them and have Medicare make sense. I enjoy talking to clients year after year, hearing about their families growing or them asking about mine.

-Melissa

Oh my gosh!! I was so confused about the Medicare Supplement process. I am turning 65 soon and am retired and have always had insurance thru my former employer. I didn’t know a thing about going on Medicare and was struggling to sort it all out.

A friend of mine recommended contacting Senior HealthCare Solutions, so I did. Melissa was FANTASTIC!! She was professional, responsive, caring and friendly. She explained the steps I needed to take, gathered my information, helped me choose good plans for MY specific needs and took care of my applications over the phone. 1-2-3, eesy-peesy and I was done!! And it didn’t cost me a DIME!!! WOW!!! I HIGHLY recommend Senior Healthcare Solutions for anyone who’s overwhelmed with making the right choices with Medicare Supplemental Insurance and Rx coverage. It’ll take a load off your mind!

Janice W.

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