What is prior authorization?

Prior authorization is often times referred to as pre-approval or pre-authorization. Prior authorization is a process through which a request is submitted to a medical review contractor before the item or service is furnished to the beneficiary and before the claim is submitted for processing. It is a process that permits the submitter/requester, often times a provider, supplier, or the beneficiary, to send in medical documentation, in advance of the items or service being rendered or billed, in order to verify its eligibility for Medicare claim payment.

For any item or service to be covered by Medicare it must:

  • Be eligible for a defined Medicare benefit category
  • Be medically reasonable and necessary for the diagnosis and treatment of illness or injury, or to improve the functioning of a malformed body member
  • Meet all other applicable Medicare coverage, coding and payment requirements

At the direction of the Centers for Medicare and Medicaid Services (CMS), a prior authorization request must be submitted for certain Durable Medicare Equipment, Prosthetics, Orthotics, and Supplies items. This is the most commonly seen request for prior authorization. If you are interested in learning more about the list of required prior authorizations from the Medicare Learning Matters document released in May of 2017, you can click here.

Additional questions regarding how prior authorization affects your current health plan? Contact Medicare Pathways at 866-466-9118 to learn more.