Medicare is the federal health insurance program covering over 65 million Americans aged 65 and older, as well as certain younger individuals with disabilities. Traditional Medicare (Parts A and B) has limited prior authorization requirements, but Medicare Advantage (Part C) plans operated by private insurers impose their own PA requirements that often mirror or exceed commercial plan requirements.
Traditional Medicare PA requests are submitted through the Medicare Administrative Contractor (MAC) for the provider's region. Medicare Advantage plans each have their own provider portals. CMS has been implementing electronic prior authorization requirements to standardize the process.
Traditional Medicare requires prior authorization for a limited set of services including certain DME, some surgical procedures, and specific diagnostic tests. However, Medicare Advantage plans, which cover over 50% of Medicare beneficiaries, can impose their own PA requirements. CMS has been taking steps to streamline and limit PA requirements, including the 2024 CMS Interoperability and Prior Authorization final rule.
Traditional Medicare generally does not require prior authorization for diagnostic imaging. However, Medicare Advantage plans frequently require PA for advanced imaging including MRI, CT, PET, and nuclear medicine studies. The CMS Interoperability and Prior Authorization rule is pushing Medicare Advantage plans to streamline their imaging PA processes.
Determine whether the patient has Traditional Medicare or Medicare Advantage. PA requirements differ dramatically.
For Medicare Advantage, identify the specific plan and check their PA requirements.
CMS mandates that Medicare Advantage plans make standard PA decisions within 7 calendar days (72 hours for expedited).
Document medical necessity using LCD/NCD criteria for Traditional Medicare.
For Medicare Advantage denials, patients have appeal rights through the Medicare appeals process.
Stay current on CMS rulemaking that may change PA requirements. The regulatory landscape is evolving quickly.
Greenlight Medical submits prior authorizations directly to Medicare, assembles all required documentation, and tracks status in real time. No portal logins, no phone holds, no fax machines.
See Greenlight in ActionTraditional Medicare has limited PA requirements, primarily for certain DME items, select surgical procedures, and specific Part B drugs. Most diagnostic imaging and standard medical services do not require PA under Traditional Medicare.
Yes, most Medicare Advantage plans require prior authorization for advanced imaging including MRI, CT, and PET scans. Requirements vary by plan. Greenlight Medical handles PA for all major Medicare Advantage plans.
CMS requires Medicare Advantage plans to make standard PA decisions within 7 calendar days and expedited decisions within 72 hours. The 2024 Interoperability and Prior Authorization rule further requires plans to implement electronic PA and provide specific reason codes for denials.
Medicare Advantage PA denials can be appealed through the plan's internal appeals process, then to an Independent Review Entity (IRE), and ultimately through the federal Medicare appeals system. Greenlight automatically prepares appeal documentation when a Medicare Advantage PA is denied.