Quick Answer: What Does Medicare Require Prior Authorization For?

Why is a prior authorization needed?

Prior authorization is designed to help prevent you from being prescribed medications you may not need, those that could interact dangerously with others you may be taking, or those that are potentially addictive.

It’s also a way for your health insurance company to manage costs for otherwise expensive medications..

Who is responsible for prior authorization?

Health care providers usually initiate the prior authorization request from your insurance company for you. However, it is your responsibility to make sure that you have prior authorization before receiving certain health care procedures, services and prescriptions.

Physicians and other healthcare providers do not usually charge for prior authorizations. Even if they wanted to, most contracts between providers and payers forbid such practices. However, there are some instances — such as when a patient is out of network — that it may be appropriate to charge for a prior auth.

What Medicare services require prior authorization?

The Centers for Medicare and Medicaid Services (CMS) has two “prior authorization required” lists. One is for durable medical equipment, mostly power wheelchairs and mattresses, and the second is for outpatient services, such as eyelid surgery, excessive skin and fatty tissue excision, nose reshaping, and vein surgery.

What services typically require prior authorizations?

The other services that typically require pre-authorization are as follows:MRI/MRAs.CT/CTA scans.PET scans.Durable Medical Equipment (DME)Medications and so on.

Does Medicare require prior authorization for DME?

A: Prior authorization of DME process has the potential to improve access to these specific items DME for dual eligible beneficiaries who need them. In many cases, Medicaid may cover DME that Medicare does not, but first requires suppliers to provide evidence that Medicare will not cover it.

Why do prior authorizations get denied?

Insurance companies can deny a request for prior authorization for reasons such as: The doctor or pharmacist didn’t complete the steps necessary. Filling the wrong paperwork or missing information such as service code or date of birth. The physician’s office neglected to contact the insurance company due to lack of …

What DME is not covered by Medicare?

There are certain kinds of durable medical equipment (DME) and supplies that Medicare does not cover, including the following: … For example, Medicare does not cover incontinence pads, catheters, surgical facemasks, or compression leggings.

What falls under durable medical equipment?

DME includes, but is not limited to, wheelchairs (manual and electric), hospital beds, traction equipment, canes, crutches, walkers, kidney machines, ventilators, oxygen, monitors, pressure mattresses, lifts, nebulizers, bili blankets and bili lights.

What should you do with the authorization number once you have prior approval?

What should you do with the authorization number once you have prior approval? Document it in the financial record and on all forms associated with the procedure.

What happens if a prior authorization is denied?

If you believe that your prior authorization was incorrectly denied, submit an appeal. Appeals are the most successful when your doctor deems your treatment is medically necessary or there was a clerical error leading to your coverage denial. One of the best ways to build your appeal case is to get your doctor’s input.

How do I submit a prior authorization to Medicare?

How do I submit an Exception or Prior Authorization request to SilverScript?To file a request by phone or to ask for help submitting your request, call Customer Care toll-free at 1-866-235-5660, 24 hours a day, 7 days a week. … To fax your written request, use our toll-free fax number: 1-855-633-7673.More items…•

Does Medicare require prior authorization for colonoscopy?

Your deductible doesn’t apply to a colonoscopy — Medicare Part B will pay for a screening colonoscopy regardless of whether you’ve met your deductible. … You’ll need to contact your insurance company prior to the colonoscopy to find out how much they may cover if you require polyp removal.

What is needed for a prior authorization?

Prior authorization for prescription drugs is required when your insurance company asks your physician to get specific medications approved by the insurance company. Prior authorization must be provided before the insurance company will provide full (or any) coverage for those medications.

Does Medicare require a referral to see a specialist?

Do I have to get a referral to see a specialist? In most cases, no. In Original Medicare, you don’t need a Referral, but the specialist must be enrolled in Medicare.

How does the prior authorization process work?

Prior authorization—sometimes called precertification or prior approval—is a health plan cost-control process by which physicians and other health care providers must obtain advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage.