doi:10.1001/jama.2024.13383MEDICARE Part CLEGISLATORSThis Medical News article discusses care denials under Medicare Advantage plans and efforts to streamline the prior authorization process.Cahan, EliJAMA: Journal of the American Medical Association...
The final rule addresses theprior authorization processand requires prior authorization approvals to be valid as long as medically necessary and states that coverage denials based on medical necessity must be reviewed by healthcare professionals with relevant expertise before issuing ...
Plans can have specific rules you must follow to get a medication covered. For example, you might need to try another medication first (a process known as step therapy), get approval from the plan beforehand (known as prior authorization), or be diagnosed with a specific condition. These req...
Prior Authorization: Some medications require prior authorization from the plan before they can be covered. This means your healthcare provider needs to provide additional information to demonstrate the medical necessity of the prescrip...
prior authorization, you have the right to appeal the decision. This process involves several stages, starting with an initial appeal to the plan, and can escalate to a review by an independent organization if necessary. Knowing how to navigate this process is crucial because it empowers yo...
A new policy is now extending the prior authorization requirement to ambulatory surgery centers starting in certain states. But at the time of the study, patients covered by traditional Medicare could have the same procedures without prior authorization at ambulatory surgery centers, which are often ...
Prior Authorization: Some medications require prior authorization from the plan before they can be covered. This means your healthcare provider needs to provide additional information to demonstrate the medical necessity of the prescription drug for your specific condition. ...
Coordinated care plans also have to offer a minimum 90-day transition period if an enrollee under treatment switches to a new MA plan. The new plan must not require prior authorization for the course of treatment. CMS sought to address concerns surrounding what the term “course of ...
This document announces the addition of 31 Healthcare Common Procedure Coding System (HCPCS) codes to the Required Prior Authorization List of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items that require prior authorization as a condition of payment. Prior authorization fo...
But the impact of these management tools on treatment patterns and health outcomes will depend on how they are implemented in practice. For instance, how cumbersome or time-consuming is a prior authorization process for physicians? Some prior authorization programs require physicians to document the ...