Medical pre-authorization Show Some medical procedures require pre-authorization before you receive treatment in order to get coverage from your health plan. Pre-authorization allows us to review your treatment within the context of any other health issues you may have and to consider the latest scientific research available to manage your condition. Some conditions have a wide range of treatment choices, and some treatments work better than others. Checking in on your progress after a series of treatments helps us make sure your treatment is effective, medically necessary and right for you. Pre-authorization helps you:
Your doctor should know which procedures require pre-authorization. If a doctor does not get pre-authorization before treating you, your health plan will not cover those costs and the doctor may bill you for that treatment. Doctors may contact our clinical partner to get pre-authorization online, by fax or by phone. If they seek pre-authorization online, they get an immediate response. They can also get pre-authorization before you arrive for your scheduled service or procedure to avoid delay. If you use an in-network doctor, you don't need to do anything. Our clinical partner evaluates your treatment plan to make sure it is the most effective treatment based on published research. Our partner also ensures that it is medically necessary and covered by your health plan. If you use an out-of-network doctor, contact us about your options. Using an out-of-network doctor may mean higher out-of-pocket costs for you. Some services that require pre-authorizationTreatment, services and equipment that may require pre-authorization:
Prescription medications that may require pre-authorization:
How to find out if a procedure requires pre-authorizationView Medicare pre-authorization requirements on our provider site. CMS runs a variety of programs that support efforts to safeguard beneficiaries’ access to medically necessary items and services while reducing improper Medicare billing and payments. Through prior
authorization and pre-claim review initiatives, CMS helps ensure compliance with Medicare rules. How They Work Prior authorization and pre-claim review are similar, but differ in the timing of the review and when services can begin. Under prior authorization, the provider or supplier submits the prior authorization request and receives the decision before services are rendered. Under pre-claim review, the provider or supplier submits the pre-claim review request and
receives the decision prior to claim submission; however, the provider or supplier can render services before submitting the request. A provider or supplier submits either the prior authorization request or pre-claim review request with all supporting medical documentation for provisional affirmation of coverage for the item or service to their Medicare Administrator Contractor (MAC). The MAC reviews the request and sends the provider or supplier an affirmed or non-affirmed decision. Benefits to Providers & Suppliers In an effort to reduce provider burden, these initiatives don’t change any medical necessity or documentation requirements. They require the same information that is currently necessary to support Medicare payment, just earlier in the process. This helps providers and suppliers address claim issues early and avoid denials and appeals. Prior authorization and pre-claim review have the added benefit of offering providers and suppliers some assurance of payment for items and services that receive provisional affirmation decisions. Current Initiatives Find out about the initiatives currently in place: Previous Initiatives Learn about previous initiatives and their results: |
Does medicare require prior authorization for physical therapy
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