PA, explained
Medicare prior authorization.
Prior authorization is your plan requiring approval before certain services. Here is when it applies, how to navigate it, and what to do if denied.
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Where prior authorization applies
- Medicare Advantage plans: very common, especially for specialty drugs, imaging, durable medical equipment, and inpatient hospital admissions.
- Original Medicare: rare. Required for a small list of specific services and durable medical equipment.
- Medigap plans: Medigap follows Original Medicare's rules; it pays after Medicare approves a service.
See our Advantage overview for how plan rules differ.
How to navigate prior authorization
- Ask your doctor's office to handle the PA request — they have the forms and medical justification.
- Get the approval IN WRITING before the service.
- Allow enough time — PA decisions can take days to weeks.
- Keep records: who you talked to, what they said, when.
If your prior authorization is denied
Plans must explain the denial and tell you how to appeal. Most appeals have a short window. The steps are usually:
- Reconsideration by the plan
- Independent Review Entity (IRE) review
- Administrative Law Judge hearing
- Medicare Appeals Council
- Federal District Court
State Health Insurance Assistance Programs (SHIPs) can help you appeal at no cost.