Prior Authorization
A Medicare Advantage or Part D requirement that a physician obtain plan approval before certain services, procedures, or medications are covered, adding administrative steps and potential delays to care.
Prior authorization (PA) requires the treating physician to submit a request to the Medicare Advantage plan or Part D insurer before delivering a service or prescribing a medication. The plan reviews whether the service is medically necessary according to its coverage criteria and approves, denies, or requests additional information. Under current federal rules, MA plans must respond to urgent PA requests within 72 hours and routine requests within 14 days.
Prior authorization is most commonly required for: specialty medications (particularly Tiers 4–5 in Part D formularies), inpatient hospital admissions (in some MA HMOs), post-acute care (SNF, home health), specialty referrals, advanced imaging (MRI, PET scans), and surgical procedures. A 2022 HHS Office of Inspector General report found that MA plans denied 13% of prior authorization requests that met Original Medicare coverage criteria.
When a PA is denied, the beneficiary or physician can request a redetermination (the plan reviews the denial internally, within 60 days), then escalation to a Qualified Independent Contractor (QIC), then to an Administrative Law Judge, then to the Medicare Appeals Council, and finally to federal district court. Denials are often overturned at the QIC stage when the physician submits complete clinical documentation.
Real-World Example
An MA plan denied prior authorization for a hip replacement surgery, citing insufficient documentation of conservative treatment failure; the physician submitted 18 months of physical therapy records and X-rays during a redetermination request, which overturned the denial within 7 days.