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Medicare Prior Authorization: Navigating Medicare Advantage vs. Original Medicare

Posted By Chris Fong October 9, 2023


Medicare is a government program that helps people in the United States get the medical care they need. Some people use Original Medicare (Part A and Part B), which is the regular plan managed by the government. Others choose Medicare Advantage plans (Part C), which are offered by private insurance companies. You can find more information about the different plan options here. It’s important to learn about getting permission for medical services, called “prior authorization,” in these two plans so you can get the right care without unexpected costs. In this blog, we’ll explain how to get prior authorization in Medicare Advantage plans and compare it to Original Medicare.

What is “Prior Authorization”?

Before we get into how to get permission, let’s talk about what “prior authorization” means. It’s like asking for permission before you can do something. In this case, it’s asking your insurance if they will pay for a certain medical service.

Getting Prior Authorization in Medicare Advantage Plans

Medicare Advantage plans are different from Original Medicare. They’re offered by private insurance companies that Medicare approves. These plans might give you extra benefits like drug coverage, dental care, hearing care, or more. Here’s how you can get permission for medical services in Medicare Advantage plans:

Step 1: Call Your Plan 

The first thing you need to do is call the company that runs your Medicare Advantage plan. You can find their phone number in your plan’s information or on their website. Ask them if you need permission for the medical service you want. They might have a list of things that need approval.

Step 2: Talk to Your Doctor 

Now, talk to your doctor about your health problem and what they think you should do about it. Your doctor can help you start the prior authorization process. They will send the right papers to your plan.

Step 3: Share the Papers 

Your doctor will send some papers to your plan. These papers are things like your medical records and test results. They will also write a note to explain why you need the medical service. All these papers will go to your plan.

Step 4: Wait for a Decision 

Your Medicare Advantage plan will look at the papers and decide within a certain time. They can say yes, which means they’ll pay for the service, or no, which means they won’t. Sometimes, they might need more information. Decisions are usually made within 72 hours of the insurance company getting all of the papers they need to decide. If you need a faster decision, your doctor can ask for a “expedited decision.” 

Step 5: If They Say No 

If your plan says no, don’t worry. You have the right to say, “I don’t agree!” Your plan will tell you how to do this. It might involve different steps, but you have a chance to explain why you think they should say yes. 

Good Things About Medicare Advantage Plans:

  • You might get more benefits like drug coverage, dental care, hearing care, and more.
  • It’s easier because you deal with just one insurance company.
  • You might pay less for some services.

Contrasting with Original Medicare

Now, let’s look at how it’s different when you have Original Medicare:

Step 1: Less Prior Authorization 

Usually, with Original Medicare, you don’t need to ask for permission for most medical services. But sometimes, things like special medical equipment might need permission.

Step 2: Your Doctor’s Help 

If something needs prior authorization, your doctor usually takes care of it. They will send the papers to Medicare for you, so you don’t have to worry about it.

Step 3: No Special Appeals Process 

Unlike Medicare Advantage plans, Original Medicare doesn’t have a special way to ask again if they say no. But you can still complain if you think they’re wrong. You can tell your state’s Quality Improvement Organization (QIO) for help.

Good Things About Original Medicare:

  • Most of the time, you don’t need to ask for permission.
  • It’s simpler because fewer things need approval.


It’s important to know how to ask for permission for medical services in Medicare Advantage plans and see how it’s different from Original Medicare. Medicare Advantage plans can give you more benefits, but they have their own rules for prior authorization. Original Medicare is usually simpler in this regard. When you pick between them, think about your health needs, what you like, and what you can afford to make the best choice for you. Remember, you have the right to get the care you need, and these rules are here to help you.