About Prior Authorization

CMS has implemented Prior Authorization (PA) programs nationwide to ensure that Medicare beneficiaries continue to receive reasonable and necessary care while protecting the Medicare Trust Fund from improper payments. PA ensures all relevant coverage, coding, payment rules and medical record requirements are met before the service is rendered to the beneficiary.

Providers must understand the requirements of each program to ensure Medicare compliance when providing hospital outpatient department (OPD) services to beneficiaries. For example, the Hospital OPD PA program is a condition of payment, whereas the Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) program allows the supplier to decide between PA and prepayment review.

The implementation of PA programs does not result in changes to documentation requirements. They do, however, support providers and suppliers by identifying inconsistencies in documentation, ultimately avoiding claim denials and the appeals process.

Revised 6/23/2025