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 n🅰ot be approved. 

With the number of required prior authorizati♔ons on the upswing, it’s important to understand how prior auth൩orizations work, when you might need one, the steps you’ll likely go through, and what you can do to speed up the process.  

What Is a Prior🥂 Authorization in Medicare Advan💯tage?

澳洲幸运5开奖号码历史查询:Medicare Advantage plans require preauthorization for many health services, drugs, or medical equipment before you receive them, except in an emergency. PAs a💝re Medicare Advanta💮ge’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. 

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 ꦡuse other,♒ likely less-expensive drugs on the plan’s drug list (formulary) that match your condition.

When and Howꦡ Often Is a Prior Authorization Required𒅌? 

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
• 澳洲幸运5开奖号码历史查询:Skilled nursing facility stays
• Inpatient hospital stays
• Diagnostic procedures, labs, and tests
• Partial hospitalization 
• Home health services

That being saಌid, 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 ins♋urer may choose to reduce the numb🅠er of services, drugs, and devices that require a PA.

How to Get a Faster Prior Authorizat🌞ion Response

By law, Medicare Advantage insurers must respond to a standard PA within 14 da⭕ys. 

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.

Steps for Prior Authorization 

You’ll typically need to work with your provid𒐪er to submit a prior authorization request. 

1. 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.
2. 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.
3. Double-check any information you provide. Offer your doctor complete and accurate information about you, your medical conditions and history, and your health care.
4. 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.
5. Follow up. Don’t assume things are moving forward. Follow up with your doctor once a week or, if needed, once a day. 

How Does an Insurer Make Prior Authorization 💃Decisions?

Generally, your plan’s clinica𓄧l specialᩚᩚᩚᩚᩚᩚ⁤⁤⁤⁤ᩚ⁤⁤⁤⁤ᩚ⁤⁤⁤⁤ᩚ𒀱ᩚᩚᩚists 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.

What t❀o Do If Your Prior Author🐲ization 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 澳洲幸运5开奖号码历史查询:appeal the Medicare Advantage denial decis🤡ion. More than 81ꦆ% 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.𓃲