Medicare Advantage prior authorization (PA) is the process you go through to get certain services and drugs approved before you receive them. The process can be frustrating, as it can take up to 14 days, and your request may not be approved.
With the number of required prior authorizations on the upswing, it’s important to understand how prior authorizations work, when you might need one, the steps you’ll likely go through, and what you can do to speed up the process.
Key Takeaways
- Medicare Advantage plans use prior authorization to control costs and ensure services, devices, and drugs are medically necessary.
- Some plans require more Medicare Advantage prior authorizations than others, but in general, costlier procedures and drugs are more likely to require a PA, no matter the plan.
- Insurers have 14 days to respond to your prior authorization request, but there is a key exception that can speed up the process.
- Usually, your doctor will make the PA request. You can speed things along by providing accurate information, keeping copies of your communications with your doctor and the insurer, and following up with your doctor once a week or even once a day.
- If your request is denied, you can work with your doctor to appeal the denial.
What Is a Prior Authorization in Medicare Advantage?
Medicare Advantage plans require preauthorization for many health services, drugs, or medical equipment before you receive them, except in an emergency. PAs are Medicare Advantage’s way of determining if your request is medically necessary.
“Medically necessary” usually refers to a treatment, drug, or service that meets accepted standards of medicine, reflects the latest standards and guidelines, and follows applicable state and federal laws.
Note
Prior authorizations are also called prior approvals, preauthorizations, or precertification.
Your provider submits a request with medical documentation before carrying out a service. The insurance company then offers a decision.
For example, a drug might only be covered for specific medical conditions but not for others. If so, the MA plan can require your prescriber to use other, likely less-expensive drugs on the plan’s drug list (formulary) that match your condition.
When and How Often Is a Prior Authorization Required?
You’re more likely to need a PA if you’re getting higher-cost services, such as:
- Durable medical equipment
- Part B drugs (including chemotherapy)
- Part D drugs
- Skilled nursing facility stays
- Inpatient hospital stays
- Diagnostic procedures, labs, and tests
- Partial hospitalization
- Home health services
That being said, the services, drugs, and devices that require PAs may vary from insurer to insurer.
Insurance companies can change their prior authorization rules. For example, an insurer may choose to reduce the number of services, drugs, and devices that require a PA.
How to Get a Faster Prior Authorization Response
By law, Medicare Advantage insurers must respond to a standard PA within 14 days.
However, you or your insurer can file an expedited request if waiting the standard 14 days could jeopardize your life, health, or ability to regain maximum function. The insurer must give you a decision within 72 hours, and that deadline drops to 24 hours if your PA is for a Part B drug.
Starting in 2026, Medicare Advantage’s standard preauthorization deadlines will change from 14 days to seven days for most PAs.
Steps for Prior Authorization
You’ll typically need to work with your provider to submit a prior authorization request.
- Research (if you can) prior authorization requirements. Ask your insurer if the drug, service, or device you need requires a PA. Although the company’s website will likely contain a complete list of all procedures requiring prior authorization, the lists can be extremely long and hard to understand, so calling is likely the fastest way to find out.
- Talk to your doctor about preauthorization. Your doctor can likely make the strongest case for approval of your request because they tend to be more familiar with your plan’s specific medical codes, rules for successful approval, and the paperwork needed for a PA.
- Double-check any information you provide. Offer your doctor complete and accurate information about you, your medical conditions and history, and your health care.
- Keep copies of your communications. Note the dates, names, and titles of people you talk to. Write down dates when you saw your doctor and when your PA form was submitted, and save any emails between you and your doctor or insurer. Make sure you meet any plan deadlines for responses or more information.
- Follow up. Don’t assume things are moving forward. Follow up with your doctor once a week or, if needed, once a day.
Tip
If you decide to take over the preauthorization request, ask your health plan how to complete the form and loop in your care provider for the details you’ll need.
How Does an Insurer Make Prior Authorization Decisions?
Generally, your plan’s clinical specialists review your medical record and supporting documentation, and compare your PA request to clinical criteria. A physician, pharmacist, or psychiatrist might also review your request or consult with your doctor.
Your insurer will notify you and your physician if it approves your PA. If your insurer denies your PA, it should send you and your physician the reason for the denial and instructions on how to appeal. Your doctor may have to participate in a review of the request with a health plan representative.
Note
If you’re frustrated with your PA experience, you can shop for other plans or insurers during Medicare open enrollment. However, finding PA-friendly plans may be challenging because a company’s record with prior authorizations isn’t public or considered in the Medicare Advantage star rating process.
What to Do If Your Prior Authorization Care Is Denied
If your PA request is denied, your insurer will send you a denial letter that explains why it didn’t approve your PA. Read the denial letter closely and work with your provider to appeal the Medicare Advantage denial decision. More than 81% of appealed prior authorization denials were overturned between 2019 and 2023, but many people don’t know about the appeals option.
Depending on the cost of the service, drug, or device in question, you might be able to appeal up to five times. Your insurer’s mandated response time ranges from seven days to 60 days during your first two appeals. If you reach a third, fourth, or fifth appeal, the process could take much longer.
Aside from appeals, your other option is to pay out of pocket. However, you will then have to bear the entire cost of the service, drug, or device.
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