Prior authorization is a type of rule that requires a health care provider to get approval from Medicare before delivering a particular service, prescription drug or item to a beneficiary.
You don’t typically need to get a Medicare prior authorization form, as your doctor, provider or pharmacist should be able to submit the form to Medicare on your behalf.
Does Medicare Require Prior Authorizations?
Beneficiaries with Original Medicare (Part A and/or Part B) generally do not need to obtain a prior authorization form for most Medicare services, such as doctor’s visits, hospitalizations, diagnostic studies or treatments.
Original Medicare beneficiaries may sometimes need to seek prior authorization for durable medical equipment (DME) and certain types of Medicare outpatient services.
It’s not uncommon, however, for beneficiaries of Medicare Advantage (Medicare Part C) plans and Medicare Part D Prescription Drug plans to need prior authorization before receiving some types of care.
Prior authorization is most common for getting certain prescription drugs covered by your plan. You may also need a prior authorization form if you’re seeking care from an out-of-network provider.
How Does Medicare Prior Authorization Work?
Prior authorization works by having your health care provider or supplier submit a prior authorization form to their Medicare Administrator Contractor (MAC). They must then wait to receive a decision before they can perform the Medicare services in question or prescribe the prescription drug being considered.
In addition to the prior authorization form, your provider should include any additional medical documentation that supports your claim for the provided service, item or medication.
How Do I Get a Prior Authorization Form From Medicare?
Medicare Part Part A and B prior authorization forms are typically not needed as prior authorization is most common with prescription drugs. In most cases, you will not have to fill out a prior authorization form yourself, as your doctor’s office or pharmacy will typically file the request on your behalf.
If you have a Medicare Advantage plan with prescription drug coverage or a standalone Medicare Part D prescription drug plan and are prescribed a medication that is denied by your pharmacy, you may initiate a request yourself for a Medicare prior authorization form for medication.
To do so, you can print out and complete this Medicare Part D prior authorization form, known as a Coverage Determination Request Form, and mail or fax it to your plan’s office. You should get assistance from your doctor when filling out a Medicare prescription prior authorization form, and be sure to get their required signature on the form. Your insurance carrier must respond within 72 hours of receiving the form.
Other Important Medicare Forms: How to File a Medicare Claim
In some instances, you may have to file a Medicare claim for care that you already received. This ensures that your health care provider is properly reimbursed and that you aren’t charged for more out-of-pocket Medicare costs than you actually owe.
To file a Medicare claim, print and complete this Medicare claim form and follow the instructions found at the bottom. Medicare.gov offers some additional instructions on how to file a Medicare claim.
It’s always a good idea to discuss Medicare coverage and prior authorization with your health care provider before you receive any treatment.
When Is Prior Authorization Required?
Generally speaking, Original Medicare beneficiaries are free to see specialists visit out-of-state doctors without getting prior authorization, as long as those doctors and providers accept Medicare.
Medicare Advantage plans may sometimes require prior authorization for things like non-emergency hospital care outside of your plan provider network, visiting specialists and some other services.
Some Medicare Part D plans may require prior authorization forms before they cover certain types of drugs, particularly more expensive brand-name drugs.
The Reason for Medicare Prior Authorizations
Prior authorization can help protect a beneficiary’s rights to covered Medicare benefits, and it can also act as a means of reducing improper billing, waste and fraud within the Medicare system. It also helps to cut down on over-utilization of unnecessary care.
Medicare coverage contains a lot of qualifiers, exceptions and other criteria. Prior authorization addresses much of the same information required for submitting Medicare claims or filing Medicare appeals, but it does so earlier in the process before the services are provided.
Prior authorization can also give peace of mind to both providers and beneficiaries that the care will be covered and reimbursed by Medicare, and it helps eliminate the risk that a patient may be stuck unexpectedly paying for surprise medical bills.
Get More Help With Prior Authorization
If you have further questions about Medicare prior authorization forms, filing a Medicare claim or how Medicare will cover a certain service or item, you can call 1-800-MEDICARE (1-800-633-4227). You may also contact your local State Health Insurance Assistance Program for help.