You don’t care about the fine print — you care about access and peace of mind.
You just want to know: Will I get the care I need when I need it? Will my plan get in the way? With many Medicare Advantage plans, the answer depends on whether your doctor gets prior authorization (PA) or a referral approved ahead of time. Skip that step — and your plan could deny the claim, leaving you stuck with the bill.
Here’s what you need to know to protect yourself.
What Prior Authorization Is — And When It’s Required
Prior authorization (PA) means that under a Medicare Advantage plan, your insurer must approve certain medical services, treatments, or equipment before you receive them — otherwise the plan might not pay.
Think of it as a gatekeeper: instead of “you go, we bill,” it’s “you ask, we approve, then you go.” In my experience, most Medicare Advantage plans make use of this gatekeeper often — especially when the care is expensive or complex.
That can include hospital stays, surgeries, specialized imaging, durable medical equipment, or other high-cost items. On the flip side, the traditional government-run Original Medicare rarely requires these prior approvals. What that means for you: if you’re on Medicare Advantage, you should assume you’ll encounter PA at some point — particularly when you need more than basic care — and plan accordingly.
Common Services That Trigger PA (Imaging, Surgeries, DME)
Medicare Advantage plans often require PA before covering:
- Advanced imaging (MRI, CT, PET scans)
- Inpatient or outpatient surgeries and hospital stays
- Durable Medical Equipment (DME) — wheelchairs, walkers, home medical equipment
- Skilled nursing facility stays, home-health services, or other high-cost care
Because of this wide net, PA isn’t a rare hiccup — it’s part of how many Advantage plans manage care.
Referrals vs. Prior Authorization: What’s the Difference?
Both involve extra steps — but they’re not the same.
- Referral: you must see your primary care doctor first, get a referral order, then see the specialist. Common in HMO-style Medicare Advantage plans.
- Prior Authorization: your doctor submits paperwork to the plan to prove the procedure or treatment is medically necessary before it happens. The insurer must approve it before you can move forward.
Some procedures may require both. That means: double the paperwork, double the risk of delay or denial — unless you stay on top of things.
Tips to Avoid Delays, Denials, and Surprise Bills
Make prior auth/referral requirements a regular part of your “doctor toolkit.”
- Ask early — at your first visit, ask: “Will this need prior authorization or a referral under my plan?”
- Use in-network providers whenever possible. Out-of-network care gets complicated.
- Make sure your doctor submits the request promptly. Your approval depends on documentation and timelines.
- Track dates — keep notes on when the request was submitted and when approval happened.
- Have a backup plan — if PA is denied but the service is urgent or important, consider appeal or switching to a plan type that won’t block medically necessary care.
Who Should Consider a Medigap Instead
You should consider a Medigap plan instead f you:
- Use specialists regularly,
- Have ongoing medical needs (imaging, therapy, equipment), or
- Want predictable coverage with fewer rules and hoops
If this is the case for you, a Medigap (Supplemental) path may make more sense than a Medicare Advantage plan because you’ll likely face fewer prior-authorization hurdles or referral requirements under the traditional Medicare structure.
FAQs
Do all Medicare Advantage plans require prior authorization?
Not for everything, but most Medicare Advantage plans require prior authorization for many higher-cost or specialized services. It’s a core part of how these plans manage care. If you enroll in Medicare Advantage, expect to run into PA at some point — especially if you need imaging, surgery, equipment, or post-hospital care.
Does Original Medicare require prior authorization too?
Rarely. Traditional Medicare generally doesn’t use PA for most services. This is one of the biggest functional differences between Original Medicare (with or without Medigap) and Medicare Advantage.
What happens if my doctor forgets to get prior authorization?
If the provider doesn’t get PA and the plan denies the claim, you may be responsible for the entire bill. That’s why it’s important to ask your doctor’s office directly: “Does this need prior authorization under my plan?”
How long does prior authorization take?
It varies. Some approvals come through in a few days; others take weeks depending on the procedure and the documentation your doctor submits. If you don’t see movement within a few business days, follow up with the provider’s office.
Do I need a referral AND prior authorization?
Sometimes. A referral gets you to the specialist. Prior authorization gets the service approved. Some services require both steps, which is why things can slow down if you’re not ahead of it.
What services most often require prior authorization?
Common triggers include MRIs, CT scans, PET scans, surgeries, durable medical equipment, skilled-nursing stays, home-health services, and certain high-cost Part B medications.
Ready to Lock in the Right Plan?
Prior authorization and referral rules on Medicare Advantage can feel like a headache, but knowing how they work gives you power. Understand what triggers a PA, plan for paperwork, and stay organized.
If you’d rather skip the uncertainty altogether — or want help comparing Advantage vs Supplemental coverage — reach out. At Brickhouse, we help you line up your care needs, weigh trade-offs, and pick the path that fits your life and health.
