Prior Authorization and Pre-Claim Review Initiatives
CMS runs a variety of programs that support efforts to safeguard beneficiaries’ access to medically necessary items and services while reducing improper Medicare billing and payments. Through prior authorization and pre-claim review initiatives, CMS helps ensure compliance with Medicare rules.
For more information, see our Prior Authorization and Pre-Claim Review Program stats in the “Downloads” section below.
How They Work
Prior authorization and pre-claim review are similar, but differ in the timing of the review and when services can begin. Under prior authorization, the provider or supplier submits the prior authorization request and receives the decision before services are rendered. Under pre-claim review, the provider or supplier submits the pre-claim review request and receives the decision prior to claim submission; however, the provider or supplier can render services before submitting the request.
A provider or supplier submits either the prior authorization request or pre-claim review request with all supporting medical documentation for provisional affirmation of coverage for the item or service to their Medicare Administrator Contractor (MAC). The MAC reviews the request and sends the provider or supplier an affirmed or non-affirmed decision.
Benefits to Providers & Suppliers
In an effort to reduce provider burden, these initiatives don’t change any medical necessity or documentation requirements. They require the same information that is currently necessary to support Medicare payment, just earlier in the process. This helps providers and suppliers address claim issues early and avoid denials and appeals. Prior authorization and pre-claim review have the added benefit of offering providers and suppliers some assurance of payment for items and services that receive provisional affirmation decisions.
Find out about the initiatives currently in place:
Learn about previous initiatives and their results: