Understanding HealthcareMedicare 101
Feb 2, 2024
5 Minute Read

Does Medicare Advantage require prior authorization? What you need to know

One of the most common questions we hear is, “Does Medicare Advantage require prior authorization (PA)?” The simple answer is, “Sometimes.” It all depends on your plan.

What is PA?

PA means your doctor must get approval from the federal Medicare program before providing a service or prescribing a medication.

When it comes to Medicare Advantage and Medicare Part D, coverage is usually plan-specific. You will need to check on your specific plan to confirm coverage determine if PA is required.

Blue KC Medicare Advantage plans and PA

Blue KC offers many plan choices, including Medicare Advantage Preferred Provider Organizations (PPOs) and Health Management Organizations (HMOs). You can explore the benefits for all plans offered in your area by downloading Blue KC Medicare Information Kit. There, you can see if PA for specific procedures and services is required. Simply look for a (PA) designation in the Evidence of Coverage (EOC) for each plan.

What services and procedures typically require PA?

You will need to check with your specific Medicare Advantage plan, but there are several services and procedures that often require PA. These may include:

  • Inpatient hospital
  • Outpatient hospital
  • Ambulatory surgical center
  • Certain lab services
  • Some types of imaging
  • Specific dental services
  • Skilled nursing facilities
  • Medicare Part B drugs

How Do I Get PA for Medicare?

Refer to your plan documents to see if your treatment requires approval. This information should be on your plan’s website. When it comes to obtaining PA, it is the same process, no matter what the service or procedure.

Your doctor will document medical necessity and send forms to your plan for approval. Your provider is responsible for requesting permissions. Be sure they receive all the information they need for submission, ensuring it’s correct. Double-check your plan’s terms as well.

More FAQs

Does Medicare require prior authorization  for surgery?

It depends on the type of surgery. Certain surgeries such as certain outpatient procedures involving the spine or face may require PA. You will need to check your plan’s EOC.

Does Medicare require prior authorization for MRI?

If the purpose of the MRI is to treat a medical issue, and all providers involved accept Medicare, Part B should cover the inpatient procedure. However, check your specific plan since a Medicare Advantage beneficiary might need PA to visit a specialist such as a radiologist.

Does Medicare require prior authorization for a CT scan?

If your CT scan is medically necessary and the provider(s) accept(s) Medicare assignment, Part B will cover it. Again, you might need PA if you have a Medicare Advantage plan.

How long does the process of getting prior authorization take?

It may take several days to a week or more for PA to take effect. It depends on the way your forms were submitted.  

Need more information?

Contact our Blue Medicare Advantage Customer Service team at 866-508-7140 Monday – Friday from 8am – 8pm from April 1 – September 30. October 1 – March 31 open 7 days a week from 8am – 8pm.

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Blue Cross and Blue Shield of Kansas City’s Blue Medicare Advantage includes both HMO and PPO plans with Medicare contracts. Enrollment in Blue Medicare Advantage depends on contract renewal.

Blue Cross and Blue Shield of Kansas City is an independent licensee of the Blue Cross and Blue Shield Association. The HMO products are offered by Blue-Advantage Plus of Kansas City, Inc. and the PPO products are offered by Missouri Valley Life and Health Insurance Company, both independent licensees of the Blue Cross and Blue Shield Association, and both wholly owned subsidiaries of Blue Cross and Blue Shield of Kansas City.

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