Medicare
Prior authorization in Medicare: when your plan has to approve first
Prior authorization means your plan must approve a service before you get it. Many Medicare Advantage plans require it for certain procedures and drugs, while Original Medicare generally does not for most services.
How it works
- Your doctor asks the plan to approve the service.
- The plan decides based on its rules and your medical records.
- If it is denied, you can appeal, and your doctor can help.
How to avoid a surprise
Ask your doctor's office whether a service needs approval and whether it has been approved before the date. Keep a record of the approval. Ask a plan which services need approval before you enroll.
Have this ready when you call
- The service and the date it is planned
- Your plan's member ID
- Your doctor's contact information
Common questions
Does Original Medicare require it?
For most services no, though a few items and services have special rules.
What if I got care without approval?
The plan may deny the claim. Ask the plan and your provider right away about options.
Related answers
Rather talk it through?
Call 855-367-1095 and a licensed agent will go through your situation with you. There is no charge to ask, and no obligation to enroll.
- Licensed insurance help
- No guaranteed eligibility, pricing, or availability
- Educational starting point
GetFastRates.com is not connected with or endorsed by the U.S. government or the federal Medicare program. Calling connects you with licensed insurance help. Plan availability, costs, benefits, and enrollment rules can vary by state, carrier, and individual situation.