Do Medicare Advantage plans require prior authorization?

What is prior authorization in Medicare Advantage?

Prior authorization is approval you may need from your Medicare Advantage plan before it covers certain services, supplies or drugs. Medicare.gov notes that if you have a Medicare Advantage plan, you'll typically need prior authorization before the plan covers certain services or supplies, and in some cases you also need a referral to see a specialist.

Asking the plan in advance whether it covers something is called an organization determination; sometimes you have to get one as prior authorization. You, your representative or your health care provider can request it, orally or in writing, and you can ask for a fast decision based on your health needs. If a plan provider refers you for a covered service or to a provider outside the network without getting an organization determination first, that's called plan-directed care, and in most cases you won't pay more than the plan's usual cost sharing.

Does Original Medicare require prior authorization?

In most cases, no: Original Medicare doesn't need approval in advance to cover your services or supplies. CMS does run prior authorization for certain items and services in Original Medicare, in which the provider or supplier sends the request to Medicare's contractor before the service. Current initiatives include certain hospital outpatient department services, repetitive scheduled non-emergency ambulance transport, and certain durable medical equipment, prosthetics, orthotics and supplies.

CMS's WISeR Model, which runs from January 1, 2026 to December 31, 2031 in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington, also reviews a select set of services in Original Medicare, like skin and tissue substitutes, electrical nerve stimulator implants and knee arthroscopy for knee osteoarthritis. Providers choose between a prior authorization request and a review after the service but before payment; CMS says the model doesn't change Medicare coverage and doesn't apply to Medicare Advantage.

What limits does Medicare put on prior authorization?

Medicare Advantage plans must cover all medically necessary services that Original Medicare covers, and CMS rules, including a Medicare Advantage rule issued in April 2023, limit how plans use prior authorization:

• Coordinated care plans may use prior authorization only to confirm the presence of a diagnosis or other medical criteria, or to make sure an item or service is medically necessary.
• Plans must follow Original Medicare's national and local coverage determinations and general coverage rules, and may use their own criteria only where Medicare's aren't fully established.
• Approval for a course of treatment must stay valid for as long as the treatment is medically necessary, and the plan can't ask you for additional approvals for that treatment.
• If you switch to a new plan during treatment, you have at least 90 days before the new plan can ask for a new prior approval for that ongoing treatment.
• Every Medicare Advantage plan must have a utilization management committee that reviews its policies each year against Original Medicare's coverage decisions.
• Emergency behavioral health services can't be subject to prior authorization.

How quickly must a plan decide on a request?

Starting January 1, 2026, CMS requires Medicare Advantage plans to send prior authorization decisions within 72 hours for expedited (urgent) requests and within 7 calendar days for standard requests. Plans must also give a specific reason when they deny a request, and must post prior authorization data on their websites each year. These CMS rules don't apply to prior authorization for drugs.

Medicare's 2027 handbook adds that starting January 1, 2027, your plan may be able to process prior authorization requests electronically, and you may be able to see the decisions in your patient portal; ask your doctor whether they use these tools.

How do I appeal a prior authorization denial?

Start with your plan. If your Medicare Advantage plan denies coverage, it must tell you in writing, and the first level of appeal is a reconsideration by the plan. Follow the directions in the denial notice and file within 65 days of the date on it; for a service you haven't gotten yet, your doctor can ask for the reconsideration for you. Include your Medicare Number, the service and why you're appealing, and any information, like a doctor's note, that supports it.

The plan has 30 days to decide an appeal for a service you haven't gotten, or 72 hours for a fast appeal if waiting could seriously jeopardize your life, health or ability to regain maximum function; the time can be extended by up to 14 days in some cases. If the plan still decides against you, your case goes automatically to an Independent Review Entity. After that come a hearing with the Office of Medicare Hearings and Appeals, review by the Medicare Appeals Council, and federal court; the hearing and court levels require a minimum amount in dispute that Medicare sets each year. See How do I appeal a Medicare denial?.

Do Medicare drug plans use prior authorization?

Yes. Medicare drug plans, and Medicare Advantage plans with drug coverage, can require prior authorization before you fill certain prescriptions: you or your prescriber contacts the plan, and your prescriber may need to show the drug is medically necessary and that you meet certain requirements. Plans may also use quantity limits and step therapy. If you or your prescriber think the plan should waive one of these rules, you can ask for an exception.