How Do You Get Prior Authorization From Medicare?


Quick Answer

For the limited circumstances that require prior authorization from Medicare, the doctor, supplier or pharmacy must submit a prior authorization request form to the appropriate Medicare Administrative Contractor, explains Medicare Interactive. In Original Medicare, beneficiaries never need prior authorization to visit any doctor, hospital or specialist. In Medicare Advantage plans, the plan provider has its own rules and process for obtaining prior authorization for certain treatments or supplies, though emergency and urgently needed services never require prior authorization, reports BadgerLaw.net.

Continue Reading
Related Videos

Full Answer

As of 2015, in 19 states, the Centers for Medicare & Medicaid Services requires a patient's physician or Durable Medical Equipment supplier to submit a prior authorization request to the Durable Medical Equipment Medicare Administrative Contractor for purchase of a power wheelchair or scooter, according to Medicare Interactive. Residents of the states of Illinois, Michigan and New Jersey must complete the prior authorization process for non-emergent hyperbaric oxygen therapy, reports the Centers for Medicare & Medicaid Services.

Under Medicare Part D prescription drug coverage, some prescription drugs not on the Medicare formulary require prior authorization before the cost is covered by Medicare, explains eHealth Medicare.

Medicare Advantage, or Part C, HMO plans typically require a beneficiary's primary care physician to provide a referral for services and specialists, notes BadgerLaw.net. The plan might require prior authorization from the HMO before certain health care services are covered.

Learn more about Health Insurance

Related Questions