If you’re comparing Medicare Advantage (MA) plans in time for annual enrollment, you’re probably weighing the pros and cons of each and figuring out how prior authorization might impact your quality of care. Read on to learn how prior authorization works and tips for checking plan requirements as you compare. 

What is prior authorization?

Essentially, prior authorization means your healthcare provider needs approval from your private insurance provider or Medicare before they provide the service or treatment. Many private insurance providers require prior authorization for certain services or procedures — for example, certain types of medication, imaging tests, or medical equipment. It’s typically your doctor’s responsibility to get pre-authorization, and they stay in touch with your insurance provider to monitor the progress of your claim.  

Medicare Advantage prior authorization

Many Medicare Advantage plans often require prior authorization to visit a specialist, see an out-of-network provider, or get a high-cost procedure, among other things. Though prior authorization doesn’t guarantee your service will be covered, approval makes it more likely that your plan will pay for it.

In 2023, Medicare Advantage providers made close to 50 million prior authorization determinations (or decisions), averaging about two requests per enrollee. MA providers denied under 8% of prior authorization requests in 2023, and 80% of denied requests that were appealed were ultimately overturned.

The treatments or services that require prior authorization depend on your plan, so it’s important to be in contact with your provider or representative about what’s required of you. 

How does Medicare prior authorization work?

The process of getting prior authorization can change depending on the service and provider, but generally, it can look like this:

1. Your doctor determines that you need a particular course of treatment, piece of equipment, or procedure and checks to see if prior authorization is required.
2. If it is, your doctor signs a prior authorization request form to attest that this service is medically necessary.
3. Your insurance provider reviews the claim, which can take up to 30 days. Then, they’ll either approve, reject, or request more information for your claim and inform you of their decision in writing.

If your prior authorization is approved, your health care provider can move forward. However, if it’s partially or fully denied, you can appeal the decision.

Tips to guide your plan enrollment decisions

As you consider different plans, it’s important to pay attention to the finer points of what each allows and what your rights are. Some things to keep an eye on include:

• Prior authorization requirements: Understanding what procedures or equipment will require prior authorization is crucial to getting the care you need in a timely manner. 

• Your appeal rights: As you assess different plans, pay attention to details on your appeal rights. That is, if your claim is denied, what rights to recourse do you have? How do you submit an appeal? What happens if your appeal is denied?

• What your doctor has to say: As the expert in the room, your healthcare provider or physician often has a lot of insight into the prior authorization process. They might also be aware of what plans might best suit your specific needs, so don’t hesitate to ask for their input.

Prior authorization policies: Does Original Medicare require prior authorization?

Whereas Medicare Advantage requires prior authorization for more than a few services, including getting non-emergent hospital care, Original Medicare requires it less frequently.

Historically, Medicare didn’t require pre-authorization at all. In the last few years, however, the law expanded to require prior authorization for certain durable medical equipment and some hospital outpatient department services. What’s more, prior authorization is coming to Medicare in six states as early as January 2026. 

While Original Medicare asks for pre-approval less frequently, it also doesn’t allow you to appeal denials. Unlike MA, which considers prior authorization a “pre-service initial determination” (making standard appeal rights and processes apply), Original Medicare does not have the same consideration.

This difference in prior authorization policies can have a strong impact on your quality of care and ought to be considered when choosing a plan. Also, consider that while MA has an appeal process, it can take a lot of intensive communication with your plan provider and last up to or longer than a month.

Work with your provider to navigate prior authorization 

Understanding the nuances in these plans can be challenging, and navigating it can be a difficult process. In the end, consider your needs: How often will you need high-cost services that require pre-authorization? Is an appeal process important to you? Answering these questions thoughtfully, talking to your doctor, and working with your insurance representative will help you make the right decision for you.