What is meant by "prior authorization" in Medicare Advantage coverage?

The concept of "prior authorization" in Medicare Advantage coverage refers specifically to the requirement that healthcare providers obtain approval from the insurance company before delivering certain medical services or procedures. This means that before a provider can perform specific treatments, tests, or services that might be costly or not universally covered, they must first seek and receive consent from the insurer. This process ensures that the service is medically necessary and meets specific criteria set by the plan.

This approach helps to control costs and ensure that patients receive appropriate care based on their individual health needs. It is important for Medicare beneficiaries to understand that not all services require prior authorization; it generally applies only to specific situations that have been identified by the insurance provider. Understanding this can help beneficiaries navigate their healthcare coverage more effectively and avoid unexpected costs.