Plan rules
Prior Authorization in Medicare Advantage
Prior authorization is a plan process used to determine whether certain services, items or drugs meet coverage requirements before they are provided or covered. Exact rules differ by plan.
Where to find the rule
Review the Evidence of Coverage, provider materials and plan communications. A provider may initiate the request, but the member should still understand the status and decision.
Before non-emergency care
- Ask whether the service requires authorization.
- Confirm who will submit the request.
- Ask what clinical information is needed.
- Record submission and decision dates.
- Do not assume provider network status replaces authorization.
If the request is denied
Read the written determination and deadline. The notice should explain the reason and appeal rights. The treating provider may be able to submit supporting documentation or request an expedited review when the applicable standard is met.
Emergency care
Emergency coverage follows separate protections and should not be delayed to seek ordinary prior authorization. Contact the plan after emergency care as required by the plan documents.
Compare plans using operations, not only benefits
Ask how a plan handles referrals, authorizations and continuity of care for ongoing treatment. These operational rules can matter as much as an advertised benefit.
Authorization is not the same as a medical order
A clinician’s order establishes the medical request; the plan’s prior authorization process determines whether specified plan requirements are met before the service or item is covered under plan rules. Authorization does not guarantee final payment if eligibility, network, coding or other requirements are not satisfied.
Requirements vary by plan, service and coverage year. Use the Evidence of Coverage and current plan procedures. Providers often submit requests, but the member should still track status for important scheduled care.
Before a scheduled service
- Confirm the exact service, code when available and location.
- Verify the ordering and rendering providers are in-network when required.
- Ask whether authorization or a referral is required.
- Record who will submit the request and by what date.
- Obtain the decision or reference number before service.
- Ask what changes require a new authorization.
If a request is denied or delayed
Read the written notice for the reason, the evidence used and appeal rights. Urgent circumstances may have expedited procedures. The treating professional can supply medical documentation, while the member or authorized representative should observe the stated deadlines.
For continuity, keep the request, clinical records supplied, decision, appeal documents and call notes. Do not rely only on an informal portal message when a formal determination is available.
Organize your Medicare questions
HCA can discuss options available through organizations the agency represents. There is no obligation to enroll.