What is Prior Authorization?
Prior authorization is a process used by health plans to control healthcare costs. Most Health Maintenance Organization (HMO) plans and some Preferred Provider Organization (PPO) plans require authorization before receiving certain treatments, medical services, or prescription drugs. Preauthorization, prior approval, and pre-approval are other terms for prior authorization.1Healthcare.gov, “Prior Authorization“, Accessed September 22, 2021
- Prior authorization is the process of requesting coverage for necessary healthcare services.
- Submitting a prior authorization request does not guarantee approval.
- The prior authorization process takes 5-10 business days.
- Most Medicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). require prior authorization for healthcare services.
- Original Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage. does not require prior authorization for Medicare-approved services under Part A or Medicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. coverage.
What is Prior Authorization in Medicare?
Prior authorization is requesting coverage from a Medicare Advantage plan or Medicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each... for services that have become a medical necessity. Each Medicare Advantage and Part D plan varies in what they cover, so it is important for beneficiaries to check with their health insurance plan to see if a referral is necessary2Medicareadvocacy.org, “Medicare Prior Authorization“, Accessed September 22, 2021. If a A person who has health care insurance through the Medicare or Medicaid programs. has an emergency situation they will not need prior authorization from their insurer, but they will still need to pay for any emergency costs not covered by their health plan3Cigna.com, “What is Prior Authorization and How Does the Process Work?“, Accessed September 22, 2021.
Beneficiaries that have Medicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. and Part B (Original Medicare) don’t need any prior authorization for medical services. They are able to see any healthcare professional that accepts Medicare and get any healthcare service without delay.2Medicareadvocacy.org, “Medicare Prior Authorization“, Accessed September 22, 2021
What is the Process of Prior Authorization?
The beneficiary’s primary care physician must first check their Medicare Advantage plan or Part D A formulary is a list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Medications not on a plan's formulary are generally not covered. to see if their medical procedure or prescription drug requires prior authorization. Once they have confirmed the beneficiary’s need for prior authorization, they will require as much information as they can provide about their condition so their insurance company can make an accurate estimation of the beneficiary’s need for the medical service or prescription drug.3Cigna.com, “What is Prior Authorization and How Does the Process Work?“, Accessed September 1, 2021
Once the request has been submitted, beneficiaries will have to wait 5-10 business days before they receive confirmation. If a prior authorization request is denied, beneficiaries can make an An appeal is an action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare Advantage plan, or your Medicare Part D plan. to Medicare to review their case if their A person or organization that’s licensed to give health care. Doctors, nurses, and hospitals are examples of health care providers. cannot find an alternative.3Cigna.com, “What is Prior Authorization and How Does the Process Work?“, Accessed September 1, 2021
What is the Difference Between Preauthorization and Prior Authorization?
There is no difference between preauthorization and prior authorization, they mean the same thing in the context of Medicare health insurance4Healthcare.gov, “Preauthorization“, Accessed September 1, 2021. They both refer to the Medicare plan reviewing their beneficiary’s eligibility for a health care service based on their condition. The same is also true for the terms precertification, prior approval, and pre-approval3Cigna.com, “What is Prior Authorization and How Does the Process Work?“, Accessed September 1, 2021.
- 1Healthcare.gov, “Prior Authorization“, Accessed September 22, 2021
- 2Medicareadvocacy.org, “Medicare Prior Authorization“, Accessed September 22, 2021
- 3Cigna.com, “What is Prior Authorization and How Does the Process Work?“, Accessed September 1, 2021
- 4Healthcare.gov, “Preauthorization“, Accessed September 1, 2021