Before the visit: prior authorization in a Medicare Advantage plan
Many Medicare Advantage plans have to approve a test, scan or procedure before you have it. That approval is called prior authorization. Here is what to ask for before the visit, so the visit doesn’t turn into a denial.
What prior authorization is for
Your plan has to cover everything Original Medicare covers, and it has to follow Medicare’s own coverage rules. It can’t use its own policies to deny something Original Medicare would cover and pay for.
Prior authorization may only be used to confirm a diagnosis or to check that a service is medically necessary.
Five things to ask for before the visit
- Ask your doctor’s office whether your plan needs prior authorization for this test, scan or procedure, and whether they have asked the plan for it.
- Check your plan’s list. Plans must post, on a public website, the list of items and services that need prior authorization. If a plan uses its own coverage criteria, those must be public too, with no login or paywall.
- Get the approval in writing before the visit.Once your plan approves a prior authorization, the approval must stay valid for the whole medically necessary course of treatment. The plan can’t later deny the claim as not medically necessary, and can take the approval back only for fraud or good cause.
- Know the clock.Since January 1, 2026, a plan has 7 calendar days to decide a standard request. If the care can’t wait, ask your doctor to request an expedited decision. Those are due within 72 hours.
- New to the plan?For at least 90 days after you join, an active course of treatment can’t be disrupted or made to wait on prior authorization, even if the provider is out of network.
If your plan says no
A prior-authorization denial comes as a written notice, the Integrated Denial Notice (form CMS-10003). That notice is itself a decision you can appeal. Since January 1, 2026, every prior-authorization denial must state the specific reason. If yours doesn’t, the first step is a letter asking for it.