Getting Approval for Medicare Services 

Some Medicare-covered services require approval before you receive care. This process is called prior authorization.

What Is Prior Authorization?

Prior authorization (sometimes called prior approval or PA) means your plan reviews certain health care services before they are provided. The review helps ensure the service is medically necessary and covered under your Medicare benefits.
Prior authorization is not required for most services.

For services that do require prior authorization, your doctor or other provider will usually submit the request on your behalf. You also have the right to request an authorization yourself.

Prior authorization is never required for emergency care. If you have a medical emergency, call 911 or go to the nearest emergency room immediately.

How Prior Authorization Works

1. Talk to Your Provider

   Let your doctor, specialist, or other health care provider know you are an Elderplan member. If a service requires prior authorization, your provider will usually submit the request on your behalf.

2. Your Provider Submits Clinical Information

   Your provider submits information about your medical condition and the requested service. This information helps us determine whether the service is medically necessary and covered under your Medicare benefits.

3. We Review the Request

   Qualified clinical staff review the request using Medicare coverage rules, medical necessity criteria, and applicable clinical guidelines.

4. We Make a Decision

   We send a written decision to both you and your provider.

   If approved, the notice will include:

   • The service that was approved
   • Any quantity, frequency, or duration limits
   • The authorization period, when applicable

   If denied, the notice will explain the reason for the decision and your appeal rights.

5. Request an Expedited Review if Needed

   If waiting for a standard decision could seriously jeopardize your health, your life, or your ability to regain maximum function, you or your provider may request an expedited review.

   Your provider should explain why a faster decision is medically necessary.

In some situations, we may take up to 14 additional calendar days if more information is needed and the delay is in your best interest. We will notify you in writing if additional time is needed.

Find Prior Authorization Requirements for Your Plan

Authorization requirements vary by plan. Select your plan below to view services that require prior authorization.
Elderplan for Medicaid Beneficiaries →
Elderplan Select →
Elderplan Advantage for Nursing Home Residents →
Elderplan Plus Long-Term Care →

What If My Request Is Denied?

If we deny a prior authorization request or approve less than what was requested, you have the right to appeal.