Prior authorization means that your Medicare Advantage plan may need to approve certain medical services, procedures, tests, equipment, or medications before they are provided.
For medical services, the healthcare provider ordering or performing the service is generally responsible for submitting the prior authorization request to the health plan. Your provider has the clinical information and documentation needed to explain why the service is medically necessary.
As the patient, however, you should still verify that the authorization process has been completed before receiving a non-emergency service.
Before a scheduled procedure or test, ask the provider’s office:
- Does this service require prior authorization?
- Has the authorization been submitted?
- Has my health plan approved it?
- Is the facility also participating in my plan’s network?
Do not assume that because an appointment has been scheduled, every insurance requirement has been completed.
If an authorization is denied, you may have appeal rights. Your provider may also be able to submit additional medical information or request reconsideration.
If you are being told that you are responsible for obtaining your own medical prior authorization, or you are caught between your provider and your health plan, contact Regional Financial Security Agency. We can help you understand the process and determine whom you should contact next.