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Medicare Advantage Prior Authorization: Rules and Timelines
Many Medicare Advantage plans require prior approval for certain services — here's how the process and timelines work.
Talk to a Licensed Agent: (302) 407-0876What Requires Prior Authorization
Prior authorization means a plan must approve certain services before you receive them, or before the plan will pay for them. Original Medicare rarely requires it, but many Medicare Advantage plans do — commonly for advanced imaging like MRIs and CT scans, inpatient hospital stays, durable medical equipment, and specialty medications.
Plans are required to publish a public list of which services need prior authorization, so you can check in advance rather than being surprised at the point of care.
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Call (302) 407-0876Timelines and Exceptions
Under current CMS rules, plans must generally make urgent prior authorization decisions within 72 hours and standard decisions within 7 calendar days. Once approved, an authorization is valid for the full course of treatment rather than requiring repeated re-approval, and any denial must come with a clear explanation and appeal instructions.
Prior authorization generally doesn't apply to emergency care, urgent care needed while out of your plan's area, stabilization immediately after an emergency, or continuity of care when you're mid-treatment and switching providers.
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