Full Definition

Under Original Medicare, prior authorization is rarely required. Under Medicare Advantage plans, prior authorization is common for high-cost services including SNF admissions, inpatient rehabilitation, home health, and certain outpatient procedures.

For hospital discharge planning, prior authorization is a critical step. The hospital case manager submits a prior authorization request to the MA plan on the patient’s behalf. The plan reviews the request — typically within 24-72 hours — and responds with approval, denial, or a request for additional information. Initial approvals are often limited in scope (a specific number of SNF days), requiring continued authorization requests for extended care.

If a prior authorization is denied, the patient has the right to appeal. The case manager should initiate the appeal, but families can and should ask about the denial reason and the appeal timeline. Expedited appeals must be resolved within 72 hours.