Georgia Medicare Prior Authorization Rules: 2024 CMS Reform Guide

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By Brevy Care Team · Last verified May 13, 2026

Prior authorization has long been one of the most contentious aspects of Medicare Advantage. Before 2024, Medicare Advantage plans operating under Section 1851 of the Social Security Act and 42 CFR Part 422 routinely required pre-approval before providing or paying for non-emergency services. Beneficiaries faced 14-day waits for routine prior authorization decisions. Plans applied internal coverage criteria that were sometimes stricter than Original Medicare. OIG investigations found that a significant share of Medicare Advantage prior authorization denials concerned care that Original Medicare would have covered (OIG report OEI-09-18-00260, April 2022). A substantial majority of denials appealed by enrollees were ultimately approved on appeal. Provider abrasion from administrative burden reached historic highs. Beginning in 2024, the Centers for Medicare and Medicaid Services issued a series of final rules that fundamentally restructured prior authorization in Medicare Advantage. The Medicare Advantage and Part D Final Rule for Contract Year 2024 (88 Fed. Reg. 22120, April 12, 2023), the CMS Interoperability and Prior Authorization Final Rule (89 Fed. Reg. 8758, February 8, 2024), and the Medicare Advantage Final Rule for Contract Year 2025 (89 Fed. Reg. 30448, April 23, 2024) together changed the rules of the road. Plans must now use Original Medicare coverage criteria for basic benefits. Standard prior authorization decisions must come within seven days. Expedited (urgent) decisions must come within 72 hours. Approved prior authorizations remain in effect for the entire course of treatment. Plans must publish their clinical criteria. Utilization management committees must include clinicians of the relevant specialty. By January 2027, all prior authorization must be available electronically through FHIR-based application programming interfaces. For Georgia's Medicare Advantage enrollees, these reforms matter. This guide explains the federal regulatory framework, the OIG findings that drove reform, each of the major 2024 final rule provisions, the five-level appeals process for prior authorization denials, the practical implementation timeline through 2027, and worked examples for typical Georgia prior authorization scenarios. :::

::: callout Key takeaways for Georgia Medicare prior authorization rules

• Under the 2024 CMS final rule (88 Fed. Reg. 22120) effective January 1, 2024, Medicare Advantage plans must use Original Medicare coverage criteria for basic Medicare-covered benefits under 42 CFR 422.138.
• Standard prior authorization decisions must be made within 7 days (reduced from 14 days under prior rules) and expedited decisions within 72 hours.
• Approved prior authorizations remain in effect for the entire course of treatment; plans cannot demand mid-treatment reauthorization for stable patients.
• Plans must publicly publish the clinical criteria they use to make coverage decisions, allowing providers to know what evidence to submit.
• GeorgiaCares (SHIP) at 1-866-552-4464 provides free counseling on prior authorization disputes and appeals. :::

How prior authorization works in Medicare Advantage

Prior authorization is a utilization management tool used by Medicare Advantage (Part C) and Medicare Part D plans to require pre-approval before the plan will pay for certain services or drugs. The legal basis sits in Section 1852 of the Social Security Act, which authorizes Medicare Advantage plans to manage covered benefits through reasonable utilization controls, and in 42 CFR Part 422, which governs MA plan operations. Plans use prior authorization to ensure that requested services are medically necessary, are covered under the plan's benefit design, and meet appropriate clinical criteria. In principle, prior authorization helps control unnecessary utilization and steer beneficiaries toward evidence-based care. In practice, prior authorization in Medicare Advantage became a flashpoint for disputes between beneficiaries, providers, and plans throughout the 2010s and early 2020s.

Original Medicare (Parts A and B) generally does not require prior authorization for most covered services. There are exceptions: certain durable medical equipment items, certain Part B drugs, and a few outpatient procedures fall under Original Medicare's limited prior authorization framework. But the vast majority of Original Medicare beneficiaries access services without pre-approval. Medicare Advantage, by contrast, relies heavily on prior authorization. A typical MA plan may require prior auth for non-emergency hospital admissions, skilled nursing facility admissions, home health care, durable medical equipment over a certain dollar threshold, diagnostic imaging (MRI, CT, PET scans), outpatient procedures with high cost, specialty drugs administered under Part B, and certain Part D specialty drugs.

The Center for Medicare and Medicaid Innovation, congressional committees, and the HHS Office of Inspector General have all studied Medicare Advantage prior authorization over the past several years. The findings were consistent: prior authorization in MA was being used in ways that diverged from Original Medicare coverage rules. Plans applied internal coverage criteria that were stricter than what Original Medicare would have covered. Plans denied medically necessary care. Plans delayed decisions beyond reasonable timeframes. Plans required reauthorization mid-treatment for stable patients. The cumulative effect was administrative burden on providers, delays in care for beneficiaries, and erosion of the principle that Medicare Advantage is equivalent to Original Medicare.

The OIG findings that drove reform

In April 2022, the HHS Office of Inspector General released report OEI-09-18-00260, titled "Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care." The report examined 250 prior authorization denials from 15 large Medicare Advantage organizations. The OIG's findings were striking. A significant share of prior authorization denials concerned services that Original Medicare would have covered. A substantial proportion of payment denials concerned services that met Original Medicare coverage rules but were denied because of plan-specific rules. In other words, MA plans were systematically applying coverage criteria more restrictive than Original Medicare, in apparent violation of the Section 1852 requirement that MA plans cover all Original Medicare benefits.

The OIG followed up with report OEI-03-22-00100, "Medicare Advantage Organizations' Prior Authorization Processes at Selected Plans," in October 2023. This report documented ongoing concerns and identified persistent issues with plans applying inappropriate coverage criteria, denying medically necessary care, and processing requests with long delays. The Senate Permanent Subcommittee on Investigations also conducted hearings and released a 2022 report documenting use of automated tools and artificial intelligence to deny prior authorization at scale, with high reversal rates on appeal. The OIG findings, the Senate report, and growing public pressure from beneficiary advocacy organizations, provider associations, and Medicare Rights Center generated the momentum for the CMS 2024 final rules.

The 2024 CMS final rule on Medicare Advantage and Part D (88 Fed. Reg. 22120)

CMS published the Medicare Advantage and Part D Contract Year 2024 Final Rule on April 12, 2023, at 88 Fed. Reg. 22120. The rule took effect January 1, 2024. It contained several major reforms to Medicare Advantage prior authorization.

The first major reform was coverage criteria standardization, codified at the new 42 CFR 422.138. The regulation states that Medicare Advantage plans must use Original Medicare coverage criteria for basic Medicare-covered services. Plans may not apply more restrictive coverage standards. When Original Medicare guidance is not specific on a particular issue, plans may use internal coverage criteria, but they must publicly disclose those criteria and base them on widely accepted clinical evidence. The practical effect: if Original Medicare would cover a skilled nursing facility admission for a particular patient, the Medicare Advantage plan must cover that same admission. The MA plan cannot impose stricter criteria, such as requiring a longer hospital stay before SNF admission than Original Medicare requires.

The second major reform was continuity of care. The 2024 rule provides that an approved prior authorization remains in effect for the entire course of treatment. Plans cannot demand mid-treatment reauthorization for stable patients. This provision is particularly important for chronic disease management, cancer treatment, long-term physical therapy, and ongoing skilled nursing care. Before 2024, plans could and did require reauthorization mid-treatment, causing disruption to care.

The third major reform was clinical criteria publication. Plans must publicly publish the clinical criteria they use to make coverage decisions. Providers can review the criteria before requesting prior authorization. Plans cannot use undisclosed or proprietary criteria. This transparency requirement allows providers to know what evidence to submit and gives beneficiaries the basis for appeals.

The fourth major reform was utilization management committee composition. The 2024 rule strengthens the requirement that decisions made by utilization management committees must involve clinicians of the relevant specialty. Oncology denials must be reviewed by an oncologist. Cardiac denials must be reviewed by a cardiologist. Mental health denials must be reviewed by a mental health professional. This provision addresses the OIG finding that non-specialist reviewers were issuing inappropriate denials.

The CMS Interoperability and Prior Authorization Final Rule (89 Fed. Reg. 8758)

CMS published the Interoperability and Prior Authorization Final Rule on February 8, 2024, at 89 Fed. Reg. 8758. The rule applies not only to Medicare Advantage but also to Medicaid, the Children's Health Insurance Program, and qualified health plans offered through the Federally Facilitated Exchanges. The rule establishes a phased implementation of electronic prior authorization workflows using FHIR (Fast Healthcare Interoperability Resources) application programming interfaces.

The rule reduces the standard prior authorization decision deadline to seven days (from the prior 14-day standard) for non-urgent requests. The expedited (urgent) decision deadline remains at 72 hours. Plans must process requests within these deadlines or the request is deemed approved.

The rule requires plans to publicly report aggregated prior authorization metrics, including:

• Number of prior authorization requests received
• Number approved
• Number denied
• Number approved after appeal
• Average response time
• Average time from approval to first service delivery

This transparency allows beneficiaries, providers, advocacy organizations, and oversight bodies to monitor plan performance and identify outliers.

The electronic prior authorization requirements phase in over 2026 and 2027. The January 2026 deadline applies to hospital admission prior authorization. By that date, plans must accept and process prior authorization requests for hospital admissions through standardized FHIR APIs. The January 2027 deadline applies to all services subject to prior authorization. By that date, the full prior authorization process for all services must be available electronically through FHIR APIs.

The electronic prior authorization framework promises substantial reductions in administrative burden. Currently, providers spend significant time on phone calls, faxes, and manual data entry to submit prior authorization requests. The FHIR API framework allows automated submission from electronic health records, automated processing on the plan side, and automated response to providers. The promise is real-time or near-real-time prior authorization decisions for routine requests.

The 2025 Medicare Advantage Final Rule (89 Fed. Reg. 30448)

CMS published the Medicare Advantage Contract Year 2025 Final Rule on April 23, 2024, at 89 Fed. Reg. 30448. The rule took effect January 1, 2025. It refined the 2024 reforms and strengthened utilization management committee composition requirements. The 2025 rule also strengthened reporting requirements for prior authorization metrics, requiring more granular and timely public disclosure.

The 2025 rule also addressed the use of artificial intelligence and algorithmic tools in prior authorization decision-making. Plans may use AI tools to assist in prior authorization review, but the final decision must involve human review when denial is being considered. AI alone cannot deny a prior authorization request. The rule responds directly to the Senate report findings about automated denials at scale.

The 2025 rule strengthened the obligation that prior authorization decisions consider all relevant factors. Plans must consider the beneficiary's clinical condition, the requesting provider's clinical judgment, and applicable Original Medicare coverage criteria. Plans must explain the basis for any denial in plain language.

Prior authorization timelines: pre-2024 vs. post-2024

Before the 2024 reforms, Medicare Advantage plans had up to 14 days to respond to standard (non-urgent) prior authorization requests and 72 hours to respond to expedited (urgent) requests. Appeals at the plan level had a 30-day standard window and a 72-hour expedited window.

After the 2024 reforms, the standard decision window is reduced to seven days. The expedited window remains 72 hours but with stricter compliance enforcement. Plan-level appeals retain the 30-day standard window and the 72-hour expedited window. Payment appeals retain the 60-day standard window.

::: table caption="Prior Authorization Decision Deadlines: Pre-2024 vs Post-2024"

A critical feature of the timeline framework is the "deemed approval" rule. If a plan fails to make a decision within the applicable deadline, the request is deemed approved. The beneficiary or provider can proceed with the service. This rule incentivizes plans to process requests within deadlines and provides a remedy when they do not.

The 5-level Medicare appeals process

When a Medicare Advantage plan denies prior authorization, the beneficiary has the right to appeal. The Medicare appeals process for MA coverage decisions has five levels.

Level 1 is plan reconsideration. The beneficiary requests that the plan reconsider its denial. The plan must respond within 30 days for standard requests and 72 hours for expedited requests. The reconsideration must be reviewed by individuals who were not involved in the original denial decision. If the request involves clinical judgment, the reviewer must be a physician with appropriate clinical expertise.

Level 2 is the Independent Review Entity (IRE). If the plan upholds the denial at Level 1, the case automatically advances to the IRE. The IRE for Medicare Advantage is Maximus Federal Services (1-833-919-0198). The IRE is independent of the plan and reviews the case afresh. The IRE must respond within 30 days for standard requests and 72 hours for expedited requests. The IRE's decision is binding unless reversed at a higher level.

Level 3 is an Administrative Law Judge (ALJ) hearing. If the IRE upholds the denial and the amount in controversy exceeds the applicable minimum threshold (adjusted annually by CMS), the beneficiary can request an ALJ hearing. ALJ hearings are conducted by the HHS Office of Medicare Hearings and Appeals. The beneficiary can present evidence, call witnesses, and have legal representation.

Level 4 is the Medicare Appeals Council (MAC). If the ALJ rules against the beneficiary, the beneficiary can request review by the MAC, which sits within the HHS Departmental Appeals Board.

Level 5 is federal district court. If the MAC rules against the beneficiary and the amount in controversy exceeds the applicable minimum threshold (adjusted annually by CMS), the beneficiary can file suit in federal district court.

Most prior authorization disputes are resolved at Level 1 or Level 2. The high reversal rate on appeal documented by OIG investigations suggests that many denials should not have been issued in the first place.

Coverage criteria standardization in detail

The new 42 CFR 422.138 is the foundation of the 2024 reforms. It requires Medicare Advantage plans to use Original Medicare coverage criteria for basic Medicare-covered services. The regulation specifies that "basic" benefits are those covered under Original Medicare under Sections 1812 and 1832 of the Social Security Act, including inpatient hospital services, skilled nursing facility services, home health services, hospice care, durable medical equipment, physician services, and laboratory services.

The implications are substantial. Before 2024, Medicare Advantage plans could and did apply coverage criteria stricter than Original Medicare. For example, an MA plan might require a 5-day hospital stay before SNF admission, when Original Medicare requires only 3 days. An MA plan might require failure of conservative treatment before approving back surgery, when Original Medicare has no such requirement. An MA plan might deny home health care for beneficiaries who could leave home with assistance, when Original Medicare covers home health care for beneficiaries who cannot leave home without considerable effort. These plan-specific restrictions are no longer permitted under 42 CFR 422.138.

When Original Medicare guidance is not specific on a particular issue (the regulation calls these gaps "areas of clinical judgment"), MA plans may use internal coverage criteria. But the internal criteria must be based on widely accepted clinical evidence (such as peer-reviewed published studies, professional society guidelines, or established standard of care) and must be publicly disclosed. Plans cannot use proprietary or secret criteria. Providers and beneficiaries can review the criteria.

Continuity of care protections

The 2024 rule establishes that an approved prior authorization remains in effect for the entire course of treatment. This provision changes the relationship between the plan and the beneficiary for ongoing care.

Before 2024, plans could and did require mid-treatment reauthorization. A cancer patient on a six-month chemotherapy regimen might be required to obtain a new prior authorization every three months. A physical therapy patient might be required to obtain a new prior authorization every 10 visits. A skilled nursing facility patient might be required to obtain a new prior authorization every 30 days. These mid-treatment reauthorizations created opportunities for plans to deny continued care, even when the beneficiary was clinically stable and benefiting from treatment.

Under the 2024 rule, mid-treatment reauthorization is generally prohibited for stable patients. The plan must honor the approved prior authorization for the entire course of treatment. Reauthorization may only be required when the treatment plan substantively changes (for example, a new drug is added, the dosage materially increases, or the goal of treatment changes).

The continuity of care provisions also apply across plan years. If a beneficiary switches MA plans at Open Enrollment (October 15 through December 7) and the new plan year begins January 1, the new plan must honor the approved prior authorization from the prior plan for in-progress treatment. The new plan cannot demand reauthorization mid-cycle. This protection is particularly important for cancer patients, chronic disease patients, and others receiving extended courses of treatment.

Clinical criteria publication

Plans must publicly publish the clinical criteria they use to make coverage decisions. The publication requirement applies to:

• Criteria for medically necessary determinations
• Criteria for skilled care determinations
• Criteria for inpatient versus outpatient determinations
• Step therapy requirements
• Quantity limits on prescription drugs

The publication must be readily accessible to providers and beneficiaries. Plans typically post the criteria on their websites, in dedicated sections for prior authorization or coverage determinations. Providers can review the criteria before requesting prior authorization and submit evidence specifically tailored to the criteria. Beneficiaries can review the criteria after a denial and identify the specific basis for the denial when filing an appeal.

The publication requirement also strengthens accountability. If a plan applies criteria that diverge from Original Medicare coverage rules, the divergence is visible. Advocacy organizations, oversight bodies, and journalists can identify plans whose criteria appear stricter than the federal standard. This transparency creates pressure for plans to align their criteria with the federal floor.

Utilization management committee composition

Plans typically use utilization management committees to review prior authorization denials. Before 2024, the composition of these committees varied widely. Some plans used non-physician reviewers for routine denials. Some plans used physicians without specialty training in the relevant area (for example, a family medicine physician reviewing an oncology denial). The Senate report and OIG findings highlighted that non-specialist review contributed to inappropriate denials.

Under the 2024 and 2025 rules, utilization management committees that review denials must include clinicians of the relevant specialty. The composition requirement is now more rigorous:

• Oncology denials reviewed by oncologists
• Cardiac denials reviewed by cardiologists
• Mental health denials reviewed by mental health professionals (psychiatrists or psychologists)
• Orthopedic denials reviewed by orthopedic surgeons or relevant orthopedic specialists
• Imaging denials reviewed by radiologists

The composition requirement applies to denial decisions. Initial approval decisions may be made by non-physician reviewers when the criteria are clear and the request meets the criteria. Denials, however, require specialist physician review.

Electronic prior authorization (e-PA) via FHIR APIs

The CMS Interoperability and Prior Authorization Final Rule establishes a roadmap to electronic prior authorization. The timeline is January 2026 for hospital admissions and January 2027 for all services.

FHIR (Fast Healthcare Interoperability Resources) is an HL7-developed standard for exchanging healthcare information electronically. FHIR APIs allow electronic health records, plan systems, and third-party applications to exchange data in real time. The CMS rule mandates that plans implement FHIR-based prior authorization APIs.

The end-state vision is automated prior authorization. A provider's electronic health record automatically submits the prior authorization request to the plan's FHIR API. The plan's system automatically reviews the request against the plan's clinical criteria. The plan's system automatically responds, often within minutes for routine requests. For complex requests requiring human review, the request is routed to the plan's utilization management committee, but the routing happens automatically and electronically. The provider's EHR receives the response and surfaces it to the provider, who proceeds with the service.

The promise is substantial reduction in administrative burden. Currently, providers spend significant time on phone calls, faxes, and manual data entry. The electronic framework eliminates most of that overhead. Beneficiaries experience faster decisions and faster service delivery.

Implementation challenges exist. Plans must build the FHIR APIs. Electronic health record vendors must integrate with the APIs. Providers must adopt the integrations. Smaller plans and smaller provider organizations may face technical and financial barriers. CMS has provided technical assistance and implementation guidance to support the transition.

Drug Price Negotiation Program interaction

Section 11401 of the Inflation Reduction Act of 2022 (Public Law 117-169) established the Medicare Drug Price Negotiation Program. The first 10 negotiated drugs take effect January 1, 2026. Under the IRA Section 11401 and the 2024 CMS rules, these selected negotiated drugs cannot be subject to prior authorization or step therapy when prescribed for an FDA-approved indication.

The first 10 selected drugs are:

• Eliquis (apixaban)
• Jardiance (empagliflozin)
• Xarelto (rivaroxaban)
• Januvia (sitagliptin)
• Farxiga (dapagliflozin)
• Entresto (sacubitril/valsartan)
• Enbrel (etanercept)
• Imbruvica (ibrutinib)
• Stelara (ustekinumab)
• Fiasp / NovoLog (insulin aspart)

For Georgia beneficiaries prescribed these drugs for an FDA-approved indication, plans cannot impose prior authorization or step therapy. The drugs must be made available on plan formularies. The prohibition on prior authorization is a critical access protection that complements the price reduction. A drug at the negotiated price is of little value if the plan can delay access through utilization management.

Georgia Medicare Advantage market landscape

Georgia has one of the largest Medicare Advantage markets in the Southeast. The major MA carriers in Georgia include:

• Humana
• UnitedHealthcare
• Aetna (CVS Health)
• Anthem Blue Cross Blue Shield
• WellCare
• Kaiser Permanente
• Cigna

Each carrier offers multiple plan types (HMO, PPO, HMO-POS, Special Needs Plans) with varying prior authorization rules. Beneficiaries selecting a plan should consult the plan's Evidence of Coverage and the plan's prior authorization list. The plan must disclose what services require prior authorization.

GeorgiaCares, the State Health Insurance Assistance Program at the Division of Aging Services, provides free unbiased counseling on Medicare Advantage selection and prior authorization disputes. GeorgiaCares can be reached at 1-866-552-4464. Counselors are trained on the 2024 reforms and can help beneficiaries understand their rights, file appeals, and identify when a denial appears to violate federal requirements.

The Georgia Office of Insurance Commissioner (1-800-656-2298) oversees consumer protection for insurance generally, including some aspects of Medicare Advantage operations. The OIC can be a complaint channel when plans appear to violate Georgia consumer protection laws.

The Atlanta Legal Aid Senior Citizens Law Project (404-377-0701) and Georgia Legal Services Program (1-800-498-9469) provide free legal assistance to low-income seniors on Medicare and other public benefit matters. They can represent beneficiaries in complex prior authorization appeals.

Worked example 1: Margaret 70 Atlanta MRI prior authorization

Margaret is a 70-year-old retiree living in Atlanta. She is enrolled in a Humana Medicare Advantage HMO plan. Margaret has been experiencing chronic lower back pain for the past six months. Her primary care physician at the Emory Healthcare network has tried conservative treatments (physical therapy, anti-inflammatory medications) without sufficient relief. The physician orders a lumbar spine MRI to evaluate for possible nerve compression or disc herniation.

Under the Humana plan, MRI imaging requires prior authorization. The physician's office submits the prior authorization request through Humana's provider portal. The request includes Margaret's clinical history, prior treatments, and clinical justification for the MRI.

Under the 2024 CMS rule (effective January 1, 2024), Humana has 7 days to respond to a standard prior authorization request (reduced from the prior 14-day standard). Under the clinical criteria publication requirement, Humana's MRI criteria are publicly available on its provider portal. The physician's office reviewed the criteria before submitting and confirmed that Margaret's case meets the criteria (chronic back pain not responsive to conservative treatment for at least 6 weeks, with clinical signs suggesting nerve involvement).

Humana approves the request within 5 days. Margaret has the MRI within 2 weeks of the order. The MRI shows mild disc bulge at L4-L5 without significant nerve compression. Margaret's physician recommends continued conservative management with addition of epidural steroid injections.

Compared to the pre-2024 experience: under the prior 14-day standard, the MRI might have been delayed up to 4 weeks from the order date. Under the clinical criteria publication requirement, the physician's office could prepare a stronger submission. Under the utilization management committee composition requirement, if the MRI had been denied, the denial would have been reviewed by a radiologist or appropriate specialist, not a generalist.

Worked example 2: Robert 75 Savannah SNF admission denial and appeal

Robert is a 75-year-old retiree living in Savannah. He is enrolled in a UnitedHealthcare Medicare Advantage PPO plan. Robert falls at home and fractures his right hip. He is admitted to Memorial Health University Medical Center in Savannah for hip replacement surgery. Following surgery, his orthopedic surgeon and case manager recommend admission to a skilled nursing facility (SNF) for rehabilitation.

UnitedHealthcare initially denies the SNF admission. The denial notice cites internal criteria stating that Robert can be discharged home with home health rehabilitation services rather than requiring inpatient SNF.

Robert's family contacts the discharge planning team and asks for an appeal. The team consults with GeorgiaCares (1-866-552-4464) and learns about the new 42 CFR 422.138 coverage criteria standardization. Under Original Medicare coverage rules, Robert's case clearly meets the criteria for SNF admission: he had a qualifying 3-day hospital stay, his physician certifies that he requires skilled care (physical therapy and occupational therapy) on a daily basis, and the skilled care is medically reasonable and necessary.

The family files an expedited appeal at the plan level. Under the 2024 rule, the appeal must be reviewed by an orthopedic specialist (relevant specialty) and decided within 72 hours. The plan-level reviewer reverses the denial. Robert is admitted to a SNF in Savannah for 20 days of inpatient rehabilitation.

Under the continuity of care provisions, the approved prior authorization covers the entire course of SNF stay (up to 100 days under Original Medicare). UnitedHealthcare cannot demand mid-treatment reauthorization to discharge Robert prematurely. Robert receives 20 days of inpatient SNF care, makes good functional progress, and is discharged home with home health services.

Worked example 3: Linda 68 Macon physical therapy expedited appeal

Linda is a 68-year-old retiree living in Macon. She is enrolled in an Aetna Medicare Advantage HMO plan. Linda underwent rotator cuff surgery 8 weeks ago and has been attending physical therapy 2 times per week at a Coliseum Health System outpatient clinic. After 12 PT visits, Aetna denies continued PT coverage, citing an internal criterion that PT after rotator cuff surgery is generally limited to 12 visits unless there is evidence of "exceptional progress" or "complex postoperative course."

Linda's physical therapist documents that she has not yet achieved her functional goals (regaining full range of motion, returning to gardening which is her primary activity of daily living). The therapist recommends 8 additional PT visits.

Linda's orthopedic surgeon files an expedited appeal, arguing that the denial threatens Linda's recovery and that the internal criterion is more restrictive than Original Medicare coverage rules. Under Section 1862(a)(1)(A) of the Social Security Act, Medicare covers physical therapy that is reasonable and necessary for treatment of the patient's condition. The 12-visit cap is a plan-specific restriction not found in Original Medicare.

Under the 2024 expedited appeal rule, Aetna must respond within 72 hours. The Aetna utilization management committee, which under the 2024 rule must include a physical medicine and rehabilitation physician or orthopedic specialist, reviews the case. The committee reverses the denial. Linda receives 8 additional PT visits and achieves her functional goals.

The continuity of care provisions ensure that the approved 8 additional visits do not require reauthorization mid-course. Aetna cannot interrupt Linda's PT at visit 16 or 18 to demand another review.

Worked example 4: Charles 73 Augusta hospital admission pre-2024 vs 2024

Charles is a 73-year-old retiree living in Augusta. He is enrolled in a Cigna Medicare Advantage HMO plan. Charles has stable coronary artery disease followed by his cardiologist at AU Health (formerly Augusta University Medical Center). His cardiologist recommends cardiac catheterization with possible percutaneous coronary intervention (stent placement) due to worsening angina.

In 2022 (pre-2024 rule), Charles's cardiologist submitted the prior authorization request to Cigna. Under the 14-day standard, Cigna took 12 days to respond, ultimately approving the procedure. Charles experienced significant anxiety during the 12-day wait, and his angina symptoms worsened during the delay. Cigna's clinical criteria were not publicly available, so the cardiologist's office had to call Cigna's provider relations to understand what evidence was needed.

In 2026 (post-2024 rule), Charles's cardiologist submits a similar prior authorization request to Cigna. Under the 7-day standard, Cigna responds within 5 days, approving the procedure. Cigna's clinical criteria are publicly published on its provider portal, allowing the cardiologist's office to prepare a complete submission on the first attempt. Under the continuity of care provisions, the approved prior authorization covers the entire course of post-procedure cardiac rehabilitation (typically 36 sessions over 12 weeks), eliminating mid-treatment reauthorization disruption.

Charles experiences faster decision, reduced anxiety, and continuous coverage of his post-procedure rehabilitation. The combined effect of the 2024 reforms is substantial: shorter wait, better evidence-based decision, and protection against mid-treatment reauthorization.

Worked example 5: Patricia 65 Columbus negotiated Eliquis no prior authorization

Patricia is a 65-year-old new Medicare beneficiary living in Columbus. She enrolled in a Humana Medicare Advantage PPO plan with prescription drug coverage (MA-PD) effective her 65th birthday. Three months into her enrollment, Patricia is diagnosed with atrial fibrillation. Her cardiologist prescribes Eliquis (apixaban) for stroke prevention.

Eliquis is one of the first 10 drugs selected for the Medicare Drug Price Negotiation Program under Section 11401 of the Inflation Reduction Act of 2022. Effective January 1, 2026, CMS has negotiated a Maximum Fair Price for Eliquis representing a substantial reduction from its pre-negotiation price.

Under Section 11401 and the 2024 CMS final rule, Humana cannot require prior authorization or step therapy for Eliquis when prescribed for an FDA-approved indication. Atrial fibrillation is an FDA-approved indication. Patricia fills her Eliquis prescription at CVS pharmacy in Columbus without any prior authorization delay.

Patricia's Part D cost-sharing for Eliquis depends on her plan's design but cannot exceed the negotiated Maximum Fair Price for the plan's reimbursement, and her out-of-pocket cost is capped under the annual Part D OOP cap that began in 2025 under IRA Section 11201. By approximately April or May, Patricia's cumulative OOP spending on Eliquis and other Part D drugs reaches $2,000, and she pays nothing for the remainder of the year.

The combined effect of Section 11401 (no prior authorization on negotiated drugs) and Section 11201 ($2,000 OOP cap) and the 2024 CMS rules (coverage criteria standardization, continuity of care) is unprecedented protection for Medicare Advantage enrollees on selected high-cost drugs.

Worked example 6: Henry 72 Athens cancer continuity of care across plan switch

Henry is a 72-year-old retiree living in Athens. He is enrolled in an Aetna Medicare Advantage HMO plan in 2025. Henry was diagnosed with non-Hodgkin lymphoma in October 2025 and started a 6-month treatment regimen of rituximab combined with chemotherapy. Aetna approved the prior authorization for the full treatment course.

During the 2025 Open Enrollment Period (October 15 through December 7, 2025), Henry compared MA plans for 2026 and decided to switch to a UnitedHealthcare Medicare Advantage HMO plan effective January 1, 2026. The switch was motivated by lower premiums and a broader oncology network in the UnitedHealthcare plan.

Under the continuity of care provisions of the 2024 CMS rule, UnitedHealthcare must honor Aetna's approved prior authorization for Henry's in-progress treatment. UnitedHealthcare cannot demand reauthorization mid-cycle. Henry's lymphoma treatment continues from January 2026 through approximately April 2026 (the end of the 6-month course) without disruption.

A new prior authorization would only be required if the treatment plan changed (for example, if the oncologist added a new drug to the regimen or changed the chemotherapy combination). For continuation of the approved regimen, the prior authorization is portable across the plan switch.

The continuity of care protections are particularly important for cancer patients, dialysis patients, transplant patients, and others on extended treatment regimens. Before 2024, plan switches could disrupt care because each new plan applied its own prior authorization requirements. The 2024 reforms align the protections with the clinical reality that treatment continuity matters for outcomes.

Common mistakes Georgia beneficiaries make

Many Georgia Medicare Advantage beneficiaries make avoidable mistakes when dealing with prior authorization. Understanding the rules helps avoid these mistakes.

The first mistake is assuming Original Medicare requires prior authorization the same way Medicare Advantage does. It does not. Original Medicare has limited prior authorization (mainly for certain durable medical equipment and a few Part B drugs). Most Original Medicare services do not require prior authorization. If a beneficiary is considering a switch between Original Medicare and Medicare Advantage, the prior authorization difference is a key factor.

The second mistake is accepting a denial without reading the reason. Plans must explain the basis for any denial in the denial notice. The basis is the starting point for any appeal. If the basis is "not medically necessary," the appeal must show medical necessity. If the basis is "service not covered," the appeal must show coverage. If the basis is "alternative treatment available," the appeal must show why the alternative is not appropriate.

The third mistake is missing the 60-day deadline to appeal. Beneficiaries have 60 days from the date of the denial notice to file a Level 1 appeal (plan reconsideration). After 60 days, the right to appeal generally expires (with limited exceptions for good cause).

The fourth mistake is not requesting an expedited appeal when health is at risk. Expedited appeals must be processed within 72 hours. Routine appeals can take up to 30 days. When the beneficiary's health is at risk from a delay, an expedited appeal is the appropriate path. The beneficiary or provider must indicate that the request is urgent and explain why.

The fifth mistake is not asking the plan for its clinical criteria. Under the 2024 rule, plans must publicly publish clinical criteria. Beneficiaries can review the criteria and identify the basis for the denial. If the criteria appear stricter than Original Medicare rules, that is grounds for appeal under 42 CFR 422.138.

The sixth mistake is confusing prior authorization with referrals. HMO plans typically require referrals from a primary care physician to specialists. PPO plans typically do not require referrals. Both HMO and PPO plans may require prior authorization for certain services regardless of referral status. Referrals and prior authorization are distinct.

The seventh mistake is not contacting GeorgiaCares for free counseling. GeorgiaCares (1-866-552-4464) is the State Health Insurance Assistance Program for Georgia. SHIP counselors are trained on Medicare rules, including the 2024 prior authorization reforms. They can help with appeals at no cost.

The eighth mistake is not knowing that emergency care does not require prior authorization. If a beneficiary needs emergency care, the beneficiary should obtain the care and not delay for prior authorization. The plan must cover emergency care regardless of prior authorization.

The ninth mistake is assuming that negotiated drugs (Eliquis, Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, Fiasp) can have prior authorization. They cannot, under Section 11401 IRA 2022 and the 2024 CMS rules, when prescribed for FDA-approved indications.

The tenth mistake is missing the deemed-approval rule. If a plan fails to make a decision within the applicable deadline (7 days for standard, 72 hours for expedited), the request is deemed approved. The beneficiary or provider can proceed with the service.

::: accordion Frequently asked questions about Georgia Medicare prior authorization rules

What is prior authorization in Medicare Advantage?

Prior authorization is a utilization management tool used by Medicare Advantage plans to require pre-approval before the plan will pay for certain services or drugs. Under Section 1852 of the Social Security Act and 42 CFR Part 422, plans may use prior authorization for non-emergency services. The plan reviews the request against its clinical criteria and either approves or denies.

What changed under the 2024 CMS final rule?

The Medicare Advantage and Part D Contract Year 2024 Final Rule (88 Fed. Reg. 22120, April 12, 2023) effective January 1, 2024 fundamentally restructured Medicare Advantage prior authorization. Key reforms: (1) coverage criteria standardization under 42 CFR 422.138 (MA plans must use Original Medicare coverage criteria for basic benefits); (2) 7-day standard decision deadline (reduced from 14 days); (3) 72-hour expedited decision deadline; (4) continuity of care protections (approved prior auth remains in effect for the course of treatment); (5) clinical criteria publication; (6) utilization management committees must include clinicians of the relevant specialty.

What is 42 CFR 422.138?

42 CFR 422.138 is a new regulation under the 2024 final rule that requires Medicare Advantage plans to use Original Medicare coverage criteria for basic Medicare-covered services. Plans may not apply more restrictive coverage standards. When Original Medicare guidance is not specific, plans may use internal coverage criteria but must publicly disclose them and base them on widely accepted clinical evidence.

How long does a Medicare Advantage plan have to make a prior authorization decision?

Under the 2024 rule, plans have 7 days to make a standard organization determination (reduced from 14 days under the pre-2024 rule) and 72 hours to make an expedited (urgent) determination. If a plan fails to make a decision within the deadline, the request is deemed approved.

What is the difference between a standard and an expedited prior authorization request?

A standard prior authorization request is for a non-urgent service. The 7-day deadline applies. An expedited prior authorization request is for an urgent service where waiting for a standard decision would seriously jeopardize the beneficiary's health or ability to regain maximum function. The 72-hour deadline applies. The beneficiary or provider must indicate that the request is urgent and explain why.

What are continuity of care protections?

Under the 2024 rule, an approved prior authorization remains in effect for the entire course of treatment. Plans cannot demand mid-treatment reauthorization for stable patients. This is particularly important for chronic disease management, cancer treatment, long-term physical therapy, and skilled nursing facility care.

Do continuity of care protections apply when I switch Medicare Advantage plans?

Yes. If you switch MA plans during Open Enrollment and your new plan year begins January 1, the new plan must honor the approved prior authorization from the prior plan for in-progress treatment. The new plan cannot demand reauthorization mid-cycle. A new prior authorization is only required if the treatment plan substantively changes.

Do plans have to publish their clinical criteria?

Yes. Under the 2024 rule, plans must publicly publish the clinical criteria they use to make coverage decisions. The criteria are typically posted on the plan's website. Providers can review the criteria before requesting prior authorization and submit evidence tailored to the criteria.

Who reviews prior authorization denials at the plan?

Under the 2024 and 2025 rules, utilization management committees that review denials must include clinicians of the relevant specialty. Oncology denials are reviewed by an oncologist, cardiac denials by a cardiologist, mental health denials by a mental health professional, and so on. Specialist review reduces inappropriate denials by non-specialists.

What is the Medicare appeals process?

The Medicare appeals process has 5 levels: (1) plan reconsideration (Level 1); (2) Independent Review Entity (IRE) review at Maximus Federal Services (Level 2); (3) Administrative Law Judge (ALJ) hearing (Level 3); (4) Medicare Appeals Council (Level 4); (5) federal district court (Level 5). Most prior authorization disputes are resolved at Level 1 or Level 2.

How long do I have to appeal a denial?

Beneficiaries have 60 days from the date of the denial notice to file a Level 1 appeal (plan reconsideration). After 60 days, the right to appeal generally expires (with limited exceptions for good cause).

What is the Independent Review Entity?

The Independent Review Entity (IRE) for Medicare Advantage is Maximus Federal Services (1-833-919-0198). The IRE is independent of the plan and reviews appeals afresh after the plan upholds a denial at Level 1. The IRE's decision is binding unless reversed at a higher level.

What is electronic prior authorization?

Electronic prior authorization (e-PA) uses FHIR (Fast Healthcare Interoperability Resources) APIs to allow automated submission, processing, and response of prior authorization requests. Under the CMS Interoperability and Prior Authorization Final Rule (89 Fed. Reg. 8758, February 8, 2024), plans must implement e-PA by January 2026 for hospital admissions and January 2027 for all services.

Do negotiated drugs require prior authorization?

No. Under Section 11401 of the Inflation Reduction Act of 2022 and the 2024 CMS rules, the 10 selected negotiated drugs effective January 2026 (Eliquis, Jardiance, Xarelto, Januvia, Farxiga, Entresto, Enbrel, Imbruvica, Stelara, Fiasp) cannot be subject to prior authorization or step therapy when prescribed for FDA-approved indications.

Does emergency care require prior authorization?

No. Emergency care does not require prior authorization. The plan must cover emergency care regardless of prior authorization status. Beneficiaries should obtain emergency care without delay.

What is the deemed-approval rule?

If a plan fails to make a prior authorization decision within the applicable deadline (7 days for standard, 72 hours for expedited), the request is deemed approved. The beneficiary or provider can proceed with the service.

Can I get help with a prior authorization appeal?

Yes. GeorgiaCares (1-866-552-4464) is Georgia's State Health Insurance Assistance Program. SHIP counselors provide free unbiased counseling on prior authorization disputes and appeals. The Medicare Rights Center (1-800-333-4114), Center for Medicare Advocacy (1-860-456-7790), and Justice in Aging (202-289-6976) also provide assistance.

What is the role of GeorgiaCares?

GeorgiaCares is Georgia's State Health Insurance Assistance Program (SHIP). GeorgiaCares provides free unbiased counseling to Georgia Medicare beneficiaries on plan selection, prior authorization, appeals, and other Medicare issues. Contact 1-866-552-4464.

What are the OIG findings that drove the 2024 reforms?

The HHS Office of Inspector General report OEI-09-18-00260 (April 2022) found that approximately 13 percent of Medicare Advantage prior authorization denials concerned services that Original Medicare would have covered, and 18 percent of payment denials concerned services that met Medicare rules but were denied due to plan-specific rules. The follow-up report OEI-03-22-00100 (October 2023) documented ongoing concerns. The Senate Permanent Subcommittee on Investigations also documented use of automated tools to deny prior authorization at scale, with 75 percent of appealed denials reversed.

What is the difference between Medicare Advantage HMO and PPO prior authorization?

HMO plans typically require referrals from a primary care physician to specialists, and also typically require prior authorization for certain services. PPO plans typically do not require referrals but may require prior authorization for certain services. Both plan types are subject to the 2024 CMS reforms (7-day standard, 72-hour expedited, continuity of care, clinical criteria publication, specialist review).

Can a Medicare Advantage plan use AI for prior authorization?

Plans may use artificial intelligence and algorithmic tools to assist in prior authorization review under the 2025 CMS rule. However, the final decision to deny a prior authorization must involve human review. AI alone cannot deny a prior authorization request. The rule responds to Senate findings about automated denials at scale.

What services typically require prior authorization in Medicare Advantage?

Services that typically require prior authorization include non-emergency hospital admissions, skilled nursing facility admissions, home health care, durable medical equipment over a dollar threshold, diagnostic imaging (MRI, CT, PET scans), outpatient procedures with high cost, specialty drugs administered under Part B, and certain Part D specialty drugs. The specific list varies by plan; the plan must disclose it in the Evidence of Coverage and on the plan's website.

What services typically do NOT require prior authorization in Medicare Advantage?

Services that typically do not require prior authorization include emergency care, urgent care, out-of-area kidney dialysis, annual wellness visits, many preventive services (vaccines, screenings), negotiated drugs under IRA 2022 (effective 2026), and ACIP-recommended vaccines under Section 11401 IRA 2022.

How can I find a plan's clinical criteria?

Under the 2024 rule, plans must publicly publish the clinical criteria they use for coverage decisions. The criteria are typically posted on the plan's website, in dedicated sections for prior authorization, coverage determinations, or medical policies. If you cannot find the criteria online, contact the plan's member services and request them.

Where can I learn more about Brevy's Medicare resources?

Brevy provides comprehensive Medicare and Medicaid resources for Georgia families at brevy.com. Our state-by-state guides cover prior authorization, appeals, drug pricing, vaccines, and more. We are committed to being the most trustworthy and up-to-date eldercare resource for American families. :::

::: cta Get help with Medicare prior authorization disputes

• DCH Medicaid Member Services 1-866-211-0950
• Medicare 1-800-MEDICARE (1-800-633-4227)
• GeorgiaCares (SHIP) 1-866-552-4464
• Georgia Office of Insurance Commissioner 1-800-656-2298
• Medicare Rights Center 1-800-333-4114
• Center for Medicare Advocacy 1-860-456-7790
• Justice in Aging 202-289-6976
• Atlanta Legal Aid Senior Citizens Law Project 404-377-0701
• Georgia Legal Services Program 1-800-498-9469
• Maximus Federal Services (Medicare IRE) 1-833-919-0198
• Palmetto GBA Georgia MAC 1-855-696-0705
• 211 Georgia
• Eldercare Locator 1-800-677-1116
• Medicare Beneficiary Ombudsman: contact through 1-800-MEDICARE
• CMS Region IV Office (Atlanta): contact through 1-800-MEDICARE
• AARP Georgia 1-866-295-7283
• Social Security Administration 1-800-772-1213 :::

This guide is provided by Brevy (brevy.com) as a public education resource. It does not constitute legal, medical, or financial advice. Medicare rules and regulations change frequently. For specific guidance on your situation, consult the agencies and organizations listed above, including GeorgiaCares (1-866-552-4464) for free unbiased counseling, or speak with a licensed Medicare agent. Last verified May 13, 2026.