Georgia Medicare Advantage Prior Authorization Rules Guide

If your Medicare Advantage plan in Georgia makes you wait for pre-approval before it will pay for an MRI, a skilled nursing stay, or a specialist procedure, the rules changed in your favor. Under the Centers for Medicare and Medicaid Services (CMS) reforms that took effect starting January 1, 2024, your plan now has seven days to decide a standard prior authorization request and 72 hours to decide an urgent one, an approved authorization stays valid for your whole course of treatment, and the plan can no longer apply coverage rules stricter than Original Medicare. One carve-out matters more than the rest, because it is the prior authorization families hit most: those decision deadlines cover medical services, not drugs. The CMS Interoperability and Prior Authorization Final Rule does not apply to prior authorization decisions for drugs at all.1 A prescription your plan is sitting on runs on the Part D coverage-determination track instead, where an expedited request must be decided within 24 hours.2

Those protections matter to a lot of people here. Georgia is a heavy Medicare Advantage state: as of March 2026, more than half of Georgia's people with Medicare were enrolled in Medicare Advantage and other health plans, 1,132,430 of 2,019,345 by CMS's count.3 For those enrollees, prior authorization is the single most common friction point between a doctor's order and getting care, and the CMS reforms rewrote how that friction works.

The changes come from a stack of federal rules: the Medicare Advantage and Part D Final Rule for Contract Year 2024 (88 Fed. Reg. 22120), the CMS Interoperability and Prior Authorization Final Rule (89 Fed. Reg. 8758), and the Medicare Advantage Final Rule for Contract Year 2025 (89 Fed. Reg. 30448). Together they set the seven-day and 72-hour deadlines, require plans to use Original Medicare coverage criteria for basic benefits under 42 CFR 422.138, keep an approved authorization in effect for the full course of treatment, force plans to publish their clinical criteria, and require specialist clinicians to review denials. The operational deadlines and public metric reporting generally began January 1, 2026; the electronic (FHIR-based) prior authorization systems generally begin January 1, 2027.1

This guide explains what each protection means for a Georgia Medicare Advantage enrollee, the ordered steps to take when a prior authorization is denied, the five-level appeals process, how the rules apply to dual-eligible Georgians in D-SNPs, and worked examples for common Georgia scenarios.

How Georgia Medicare prior authorization rules work

Georgia Medicare Advantage prior authorization is a utilization management tool that Medicare Advantage (Part C) and Medicare Part D plans use 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 confirm that a requested service is medically necessary, is covered under the plan's benefit design, and meets appropriate clinical criteria. In principle this steers care toward evidence-based treatment; in practice, prior authorization in Medicare Advantage became a flashpoint for disputes between beneficiaries, providers, and plans throughout the 2010s and early 2020s.

The key contrast for any Georgian weighing Original Medicare against Medicare Advantage: Original Medicare (Parts A and B) does not require prior authorization for most covered services. It has narrow exceptions, mainly certain durable medical equipment and prosthetics on CMS's required prior authorization list (such as some power wheelchairs), a defined set of hospital outpatient department procedures, and repetitive scheduled non-emergent ambulance transport.5 The vast majority of Original Medicare beneficiaries otherwise access services without pre-approval. Medicare Advantage, by contrast, relies heavily on prior authorization. A typical MA plan may require it for non-emergency hospital admissions, skilled nursing facility admissions, home health care, durable medical equipment over a dollar threshold, diagnostic imaging (MRI, CT, and PET scans), high-cost outpatient procedures, 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.

What to do if your Georgia Medicare Advantage prior authorization is denied

If your plan denies a prior authorization, you have concrete rights and a short clock. Work these steps in order.

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 OIG drew a stratified random sample of denials issued in June 2019 by 15 of the largest Medicare Advantage organizations, including 250 prior authorization denials. Among the prior authorization requests those plans denied, 13 percent met Medicare coverage rules, meaning the services likely would have been approved under Original Medicare. Among the payment requests they denied, 18 percent met both Medicare coverage rules and the plan's own billing rules. The OIG traced those denials to three causes: plan clinical criteria not found in Medicare coverage rules, requests for extra documentation the rules did not require, and manual or system processing errors. In a measurable share of cases, in other words, MA plans were applying coverage criteria more restrictive than Original Medicare, in tension with the Section 1852 requirement that MA plans cover all Original Medicare benefits.8

An earlier OIG report, OEI-09-16-00410 (2018), looked at what happened when denials were challenged: during 2014 through 2016, Medicare Advantage organizations overturned 75 percent of their own preauthorization and payment denials that beneficiaries and providers appealed, about 216,000 denials a year. Only a small share of denials were appealed at all, so most of that reversible care was never contested. The practical lesson for a Georgian holding a denial letter is the plainest one on this page: appeal.8

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 the 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. Under the CY2024 rule (CMS-4201-F), a Medicare Advantage plan must use Traditional (Original) Medicare coverage criteria when it makes a medical-necessity decision on a basic benefit, complying with national coverage determinations, local coverage decisions, and the general coverage rules in Traditional Medicare (42 CFR 422.101(b)). A plan may apply its own internal criteria only where Medicare criteria are not fully established, and only if those criteria are publicly accessible and based on current clinical evidence (42 CFR 422.101(b)(6)). The prior authorization approval-finality rule is codified at 42 CFR 422.138: once a plan approves an item or service, it cannot later deny coverage for lack of medical necessity or reopen that decision except for good cause or evidence of fraud.6 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 and cannot impose a stricter threshold, such as demanding 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, and plans cannot demand mid-treatment reauthorization for stable patients. The rule also guarantees a minimum 90-day transition period for any active course of treatment when an enrollee joins a plan after starting that treatment, even from an out-of-network provider (42 CFR 422.112(b)(8)(i)(B)).6 These protections are 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. It applies not only to Medicare Advantage but also to Medicaid, the Children's Health Insurance Program, and qualified health plans on the Federally Facilitated Exchanges, and it reduces the standard decision deadline to seven days (from 14) while keeping the expedited deadline at 72 hours. Those two decision timeframes are the one piece that does not reach every payer the rule covers: qualified health plan issuers on the Federally Facilitated Exchanges are excluded from them.1

The second limit is larger, and it decides whether this rule helps you at all: none of its policies apply to prior authorization decisions for drugs. CMS says so plainly in the rule's own denial-reason provision, that as with all policies in the final rule, it does not apply to prior authorization decisions for drugs, and drug prior authorizations are left out of the Patient Access API data as well.1 Prescriptions are the prior authorization most Medicare beneficiaries actually run into, so this is not a technicality. If your Medicare Advantage plan is holding up an expensive drug, counting down a 72-hour deadline that does not apply to your request can cost days on a cancer or cardiac prescription. Ask the plan for an expedited coverage determination on the drug side instead: it must decide a fast request within 24 hours, and a standard request within 72 hours of receiving it.2

The rule also 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 rule's requirements phase in across two compliance dates. The operational provisions generally begin January 1, 2026: impacted payers other than qualified health plan issuers on the Federally Facilitated Exchanges must decide expedited requests within 72 hours and standard requests within 7 calendar days, and impacted payers must give a specific reason for each denial and publicly report prior authorization metrics (the first CY2025 metrics posted by March 31, 2026). The FHIR-based API requirements carry a separate, later date that generally begins January 1, 2027.1

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.

Georgia Medicare prior authorization rules: timelines before and after the reforms

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 reforms, the standard decision window drops to seven calendar days, and the expedited window stays at 72 hours but with stricter compliance enforcement and public reporting of how often plans meet it.1 Plan-level appeals keep the 30-day standard and 72-hour expedited windows, and payment appeals keep the 60-day standard window.7

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.7

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 plan must automatically forward the case to the Part C IRE, a contractor independent of the plan that reviews the case afresh. As of May 1, 2026, the CMS Part C IRE contractor is C2C Innovative Solutions, Inc.; MAXIMUS Federal Services was the prior contractor and processed requests received through April 30, 2026.9 The IRE must respond within 30 days for standard requests and 72 hours for expedited requests, and its 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 is at least $200 for calendar year 2026 (a threshold CMS adjusts annually for inflation), the beneficiary can request an ALJ hearing.7 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. If the ALJ rules against the beneficiary, the beneficiary can request review by the Council, which sits within the HHS Departmental Appeals Board.

Level 5 is federal district court. If the Council rules against the beneficiary and the amount in controversy is at least $1,960 for calendar year 2026 (also adjusted annually by CMS), the beneficiary can file suit in federal district court.7

Coverage criteria standardization in detail

The 2024 coverage-criteria rules are the foundation of the reforms. They require Medicare Advantage plans to use Original Medicare coverage criteria for basic Medicare-covered services, and the prior authorization approval-finality protection is codified at 42 CFR 422.138.6 "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, plans could require a 5-day hospital stay before SNF admission when Original Medicare requires only three days, demand failure of conservative treatment before back surgery when Original Medicare has no such requirement, or deny home health for beneficiaries Original Medicare would cover. Those plan-specific restrictions are no longer permitted. Where Medicare guidance is not specific (the regulation calls these "areas of clinical judgment"), a plan may use internal criteria only if they are evidence-based and publicly disclosed, never proprietary or secret.

Continuity of care protections

The 2024 rule establishes that an approved prior authorization remains in effect for the entire course of treatment, changing the relationship between plan and beneficiary for ongoing care. Before 2024, plans could require mid-treatment reauthorization, for example a new authorization every three months of chemotherapy or every 30 days of skilled nursing care, creating repeated chances to cut off care for a stable, improving patient.

Under the 2024 rule, mid-treatment reauthorization is generally prohibited for stable patients. The plan must honor the approved authorization for the entire course, and reauthorization may be required only when the treatment plan substantively changes (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 and provide at least a 90-day transition period for that active course of treatment.6 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 criteria must be readily accessible, typically posted on the plan's website. Providers can review them before requesting prior authorization and tailor their evidence to them; beneficiaries can review them after a denial to pinpoint the basis for an appeal. Publication also makes divergence from the federal floor visible, so advocates and oversight bodies can spot plans whose criteria run stricter than Original Medicare.

Utilization management committee composition

Before 2024, the composition of the committees that review denials varied widely, and some plans used non-specialist physicians (a family medicine physician reviewing an oncology denial, for example), which the Senate and OIG findings tied to inappropriate denials. Under the 2024 and 2025 rules, committees that review denials must include clinicians of the relevant specialty:

• 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 requirement applies to denials. Initial approvals may still be made by non-physician reviewers when the criteria are clear and met; denials, however, require specialist physician review.

Electronic prior authorization (e-PA) via FHIR APIs

The CMS Interoperability and Prior Authorization Final Rule also builds toward electronic prior authorization. Beginning January 1, 2027, plans must implement FHIR (Fast Healthcare Interoperability Resources) application programming interfaces so a provider's electronic health record can submit a request, the plan can review it against published criteria, and a decision can return in near real time for routine cases.1 The aim is to replace today's phone-call, fax, and manual-entry workload with automated submission and response, cutting administrative burden and speeding decisions. Smaller plans and provider organizations may face technical barriers during the transition, and CMS has issued implementation guidance to support it.

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

More than half of Georgia's Medicare beneficiaries are in a Medicare Advantage plan. As of March 2026, CMS counted 1,132,430 of the state's 2,019,345 people with Medicare enrolled in Medicare Advantage and other health plans, with 886,915 in Original Medicare. For the 2026 plan year, CMS reports 180 Medicare Advantage plans available in Georgia, compared to 178 in 2025, and the average monthly MA premium changed from $13.76 in 2025 to $6.74 in 2026. That 180 is a statewide count, not the number of plans in front of any one shopper: a separate KFF analysis of the CMS landscape files, which counts only plans open to general enrollment and excludes Special Needs and employer plans, counts 102 such plans in Georgia and finds the average Georgia beneficiary chooses among 47 plans offered by an average of 8 insurers.3

Plans come in several types (HMO, PPO, HMO-POS, Special Needs Plans), each with its own prior authorization rules. Beneficiaries selecting a plan should consult the plan's Evidence of Coverage and its Annual Notice of Change (ANOC), along with the plan's prior authorization list. The plan must disclose what services require prior authorization.

GeorgiaCares, Georgia's State Health Insurance Assistance Program (SHIP) administered by the Division of Aging Services under the Department of Human Services, provides free, unbiased counseling on Medicare Advantage selection and prior authorization disputes. GeorgiaCares counselors are available Monday through Friday, 8 a.m. to 5 p.m., at 1-866-552-4464 (option 4); they do not sell insurance and take no compensation from insurers.4 Counselors 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.10

Prior authorization for dual-eligible Georgians and D-SNPs

If you have both Medicare and full Georgia Medicaid, you are a dual eligible, and the prior authorization rules reach you in two layers. On the Medicare side, most dual eligibles who choose a Medicare Advantage plan enroll in a Dual Eligible Special Needs Plan (D-SNP), a Medicare Advantage plan built for people with both coverages. D-SNPs operating in Georgia for 2026 include plans from UnitedHealthcare Community Plan and CareSource. Because a D-SNP is a Medicare Advantage plan, every 2024 prior authorization protection on this page applies to it: the seven-day and 72-hour deadlines, the Original Medicare coverage-criteria floor, continuity of care, and specialist review of denials.11

Georgia's dual-eligible integration is looser than in states that run a single integrated Medicare-Medicaid plan. Most Georgia Medicaid members are in the Georgia Families managed care program, but Medicaid long-term services and supports for older adults are delivered through home- and community-based waivers, the Community Care Services Program (CCSP) and SOURCE, rather than through one integrated plan.11 That matters for prior authorization because a service your D-SNP denies under Medicare may still be covered on the Georgia Medicaid side, and vice versa, so a dual eligible often has two coverage paths and two appeal tracks. GeorgiaCares can help you sort out which program should authorize a given service before you appeal to the wrong one.

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 2024 coverage-criteria standardization. Under Original Medicare coverage rules, Robert's case clearly meets the criteria for SNF admission: he had a qualifying inpatient hospital stay of at least three consecutive days, 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.12

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 course of the SNF stay, which Original Medicare covers up to 100 days per benefit period (days 1 through 20 in full, days 21 through 100 with a daily coinsurance).12 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: 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, and her out-of-pocket spending is capped by the annual Part D out-of-pocket threshold that the Inflation Reduction Act put in place (the cap was $2,000 in 2025 and is $2,100 for 2026). Once her cumulative out-of-pocket spending on Eliquis and her other Part D drugs reaches $2,100 during 2026, she pays nothing for covered Part D drugs for the rest of the year.13

The combined effect of no prior authorization on negotiated drugs, the annual Part D out-of-pocket cap, and the 2024 CMS coverage-criteria and continuity-of-care rules is strong protection for Medicare Advantage enrollees on selected high-cost drugs.

Worked example 4: 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 and provide at least a 90-day transition period for that active course of treatment.6 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

A few avoidable mistakes trip up Georgia Medicare Advantage enrollees dealing with prior authorization:

• Assuming Original Medicare works the same way. Original Medicare requires prior authorization only in narrow cases; most services need none. The difference is a key factor when weighing a switch between Original Medicare and Medicare Advantage.
• Accepting a denial without reading the reason. Plans must state the specific basis, and that basis is where your appeal starts. "Not medically necessary" calls for medical-necessity evidence; "service not covered" calls for coverage evidence.
• Missing the 60-day appeal deadline. You have 60 days from the denial notice to file a Level 1 appeal, with only limited good-cause exceptions after that.
• Not requesting an expedited appeal when health is at risk. A fast appeal must be decided within 72 hours versus up to 30 days for a routine one; say the request is urgent and why.
• Not asking for the plan's clinical criteria. If the published criteria look stricter than Original Medicare, that is grounds for appeal under 42 CFR 422.138.
• Confusing prior authorization with referrals. HMO plans usually require referrals to specialists and PPOs usually do not, but either may require prior authorization regardless. The two are distinct.
• Not calling GeorgiaCares. SHIP counselors help with appeals at no cost: 1-866-552-4464.
• Delaying emergency care for pre-approval. Emergency care never requires prior authorization; get the care.
• Assuming negotiated drugs can carry prior authorization. The 10 selected drugs cannot, for FDA-approved indications.
• Missing the deemed-approval rule. If the plan blows its deadline (7 days standard, 72 hours expedited), the request is deemed approved and you can proceed.
• Waiting out the 72 hours on a drug. The interoperability rule's decision deadlines do not apply to prior authorization decisions for drugs.1 Ask for an expedited coverage determination, which the plan must decide within 24 hours, rather than counting down a clock that does not run on your request.2

Where to get help with a Georgia prior authorization dispute

Learn More

Find personalized help navigating Georgia Medicare prior authorization at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.