Frequently Asked Questions About Medicare Prior Authorization
Does the WISeR pilot affect emergency hospital care?
No. Emergency department services are completely exempt from WISeR requirements. If you experience an acute medical emergency, hospital teams will provide immediate treatment without awaiting prior approval.
How can I tell if my Medicare Advantage denial was reviewed by a doctor?
Under rules enforced by CMS, your denial notice must state the specific clinical criteria used. The review must be conducted by a licensed physician with expertise in the relevant field.
You have the legal right to request the medical reviewer’s credentials directly from your plan.
Do the new seven-day turnaround rules apply to prescription medications?
The seven-day rule established under CMS-0057-F applies only to medical services and equipment, not prescription drugs. However, proposed rule CMS-0062-P aims to extend similar rapid timelines to Part D medications starting in October 2027.
Where can I view my plan’s authorization approval and denial history?
Under federal rules effective March 31, 2026, Medicare Advantage insurers must publish their annual authorization statistics directly on their public websites. You can review approval percentages and appeal overturn rates before selecting a plan.
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