Dear Representative Roe:
Thank you for the letter regarding the use of prior authorization in Medicare Advantage (MA).
appreciate hearing your views on this issue.
Medicare law and regulations allow MA plans to have prior authorization requirements that are
consistent with original Medicare coverage criteria. MA plans may require prior authorization
on medical items and services, except for emergency services, urgent care, and stabilization
services. MA plans are expected to annually review their prior authorization requirements so
that they are up-to-date with current clinical criteria and Medicare’s local and national coverage
decisions.
In the contract year 2019 Final Call Letter, the Centers for Medicare & Medicaid (CMS)
reminded MA plans that they should be transparent about prior authorization policies and
provide adequate notice to providers and enrollees of prior authorization requirements. MA
plans should specify any coverage restrictions, including what information is needed when a
provider submits a prior authorization request. In addition, MA plans must include information
about which services require prior authorization in the plan’s Evidence of Coverage that is
provided annually to enrollees. CMS also requires plans to specify this information in their
provider contracts, as well as in other provider communications/materials ( e.g., provider
manuals).
…
Read full letter here
