Prior Authorization

About Prior Authorization

CMS has implemented Prior Authorization (PA) programs nationwide to ensure that Medicare beneficiaries continue to receive medically 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 or before the claim is submitted for payment.

It is important for providers to understand the implementation of each program they are participating in to ensure Medicare compliance when rendering services to their beneficiaries. For example, The Hospital Outpatient Department (OPD) PA program is a condition of payment, whereas the newly implemented Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) allows the supplier to decide between PA and prepayment review.

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

Revised 5/3/2024