[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-detail-216945-en":3,"doc-seo-216945-105":31,"detail-sidebar-cat-0-en-105":101},{"code":4,"msg":5,"data":6},0,"success",{"doc_id":7,"user_id":8,"nickname":9,"user_avatar":10,"doc_module":4,"category_id":11,"category_name":12,"doc_title":13,"doc_description":14,"doc_content":15,"file_id":16,"file_url":17,"file_type":18,"file_size":19,"view_count":20,"is_deleted":4,"is_public":21,"is_downloadable":21,"audit_status":21,"page_count":22,"language":23,"language_code":24,"site_id":25,"html_lang":24,"table_of_contents":26,"faqs":27,"seo_title":28,"seo_description":14,"update_tm":29,"read_time":30},216945,962085320529,"Sarah ","https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc",7,"Healthcare","2025-2026 Medicare Prior Authorization Grid - Prior authorization requirements","2025-2026 Medicare prior authorization grid defines when authorization is required for covered services and when it is not. It outlines eligibility rules, including medical necessity requirements, CMS regulation constraints, and how in-network versus out-of-network services differ for HMO/SNP and PPO members. The grid also addresses retroactive requests, emergent and urgent exceptions, inpatient notification needs, and guidance to search codes across categories, plus detailed service groupings such as inpatient, SNF, home health, therapy thresholds, rehabilitation visit limits, ambulances, and DME criteria.","2025-2026 Medicare Prior Authorization Grid  \n1. Services NOT reflected on this authorization grid DO NOT require authorization.  \n2. All services must be medically necessary, subject to CMS regulations.  \n3. Payment is based on benefits in effect at the time of service, member eligibility and medical necessity.  \n4. HMO/SNP members require a prior authorization for ALL out-of-network services.  \n5. PPO Plans do NOT require a prior authorization for out-of-network services.  \n6. Retroactive requests (services already rendered) need to be submitted as a claim.  \n7. Prior authorization is NOT required for emergent inpatient admission; however, authorization of an inpatient stay is required prior to claim payment. Please submit anotification to allow for authorization entry and concurrent review.  \n8. Codes may not be categorized in an area that is familiar so please search the entire document.  \n9. Emergent/Urgent Services do not require prior authorization, please make sure to follow appropriate billing practices to indicate emergency/urgent if applicable.  \nThis first table is a high-level listing of PAs required. Codes by Category can be found on the following pages, listed in alphabetical order by category.  \nY0084_PROV_PAG_2025_C  \n\n| Authorization is required for the following services/procedures |  |  |\n| --- | --- | --- |\n| Inpatient Hospital Services |  |  |\n| Inpatient Hospital / Inpatient Rehabilitation / Psychiatric Inpatient Hospital / Planned\u003Cbr>Inpatient Surgeries |  |  |\n|  |  |  |\n| Skilled Nursing Facility Services |  |  |\n| All SNF Services |  |  |\n| Home Health Services |  |  |\n| All Home Health Services |  |  |\n| Occupational Therapy Services, Physical, and Speech Therapy Services – PPO\u003Cbr>Plans Only |  |  |\n| Occupational Therapy, Physical Therapy, and Speech Therapy require prior authorization after the first 20 visits (combined) per plan year. |  |  |\n| Cardiac Rehabilitation Services |  |  |\n| Cardiac Rehabilitation Services require prior authorization after the first 36 visits per plan year |  |  |\n| Pulmonary Rehabilitation Services |  |  |\n| Pulmonary Rehabilitation Services require prior authorization after the first 36 visits per plan\u003Cbr>year |  |  |\n| Ambulance Services |  |  |\n| Only non-emergency ambulance transportation requires prior authorization |  |  |\n| Durable Medical Equipment (DME), Prosthetics/Medical Supplies and Diabetic\u003Cbr>Supplies and Services |  |  |\n| All DME Rentals |  |  |\n| DME purchases exceeding $750.00 (billed amount per line item) |  |  |\n| Prosthetics/Medical Supplies purchases exceeding $750.00 (billed amount per line\u003Cbr>item) |  |  |\n| Continuous Blood Glucose Monitors require prior authorization, regardless of cost or brand |  |  |\n| Diabetic supplies and services exceeding $750.00 billed amount and for blood glucose monitoring supplies exceeding the following limits: |  |  |\n| • 100 test strips and 100 lancets per 90-day supply for individuals who are non-Insulin dependent |  |  |\n| • 300 test strips and 300 lancets per 90-day supply for individuals who are Insulin dependent |  |  |\n|  |  |  |\n| 1 lancet device per 6 months for both Insulin dependent and non-Insulin dependent individuals |  |  |\n| 1 continuous glucose monitor per 6 months for both Insulin dependent and non-Insulin dependent individuals |  |  |\n| Preferred Glucose Meters: |  |  |\n| • OneTouch Verio Reflect and Verio Flex |  |  |\n\n\n| • FreeStyle Lite and Freedom Lite |  |  |\n| --- | --- | --- |\n| Preferred Test Strips: |  |  |\n| • OneTouch Ultra Blue |  |  |\n| • OneTouch Verio |  |  |\n| • FreeStyle Lite |  |  |\n| • FreeStyle |  |  |\n| • FreeStyle Precision Neo |  |  |\n| • Precision Xtra |  |  |\n| • Precision Xtra Beta Ketone Strips |  |  |\n|  |  |  |\n| Preferred Continuous Glucose Monitors |  |  |\n| • Abbott’s FreeStyle Libre 2 and 3 |  |  |\n| • Dexcom’s G6 and G7 |  |  |\n| *Non-preferred test strips and monitoring systems require prior authorization, regardless of quantity. |  |  |\n|  |  |  |\n| Other Servic","cbCaig40zQvED4Id","https://ap.wps.com/l/cbCaig40zQvED4Id","pdf",1492138,2,1,93,"English","en",105,"# Prior authorization rules\n## Service categories requiring authorization\n## Inpatient and facility services\n## Therapy and rehabilitation visit thresholds\n## Ambulance and durable medical equipment (DME)\n## Code lists by service area","[{\"question\":\"哪些服务不需要事先授权？\",\"answer\":\"不在该授权表所列范围内的服务不需要授权。紧急住院情形也有特定例外规则。\"},{\"question\":\"HMO/SNP 与 PPO 在门外服务授权要求上有什么区别？\",\"answer\":\"HMO/SNP 成员对所有门外（out-of-network）服务都需要事先授权；PPO 计划对门外服务不需要事先授权。\"},{\"question\":\"已经完成的服务如果需要追溯授权怎么办？\",\"answer\":\"追溯请求（已提供的服务）需要作为索赔（claim）提交，而不是走事先授权流程。\"},{\"question\":\"紧急或急诊服务是否需要授权？\",\"answer\":\"紧急（emergent）住院不要求事先授权，但住院期间需在索赔付款前完成授权；需提交通知以录入授权并进行并行评审。紧急/急需服务通常也不需要事先授权，但需按适当的账单做法在必要时标识为紧急/急需。\"}]","2025-2026 Medicare Prior Authorization Grid - Prior authorization requirements | PDF",1788828538,234,{"code":4,"msg":32,"data":33},"ok",{"site_id":25,"language":24,"slug":34,"title":13,"keywords":35,"description":14,"schema_data":36,"social_meta":96,"head_meta":98,"extra_data":100,"updated_unix":29},"2025-2026-medicare-prior-authorization-grid-prior-authorization-requirements","",{"@graph":37,"@context":95},[38,54,74],{"@type":39,"itemListElement":40},"BreadcrumbList",[41,45,48,51],{"item":42,"name":43,"@type":44,"position":21},"https://docshare.wps.com","Home","ListItem",{"item":46,"name":47,"@type":44,"position":20},"https://docshare.wps.com/document/","Document",{"item":49,"name":12,"@type":44,"position":50},"https://docshare.wps.com/document/healthcare/",3,{"item":52,"name":13,"@type":44,"position":53},"https://docshare.wps.com/document/2025-2026-medicare-prior-authorization-grid-prior-authorization-requirements/216945/",4,{"url":52,"name":13,"@type":55,"image":56,"author":61,"headline":13,"publisher":63,"fileFormat":66,"inLanguage":24,"description":14,"dateModified":67,"datePublished":68,"encodingFormat":66,"isAccessibleForFree":69,"interactionStatistic":70},"DigitalDocument",{"url":57,"@type":58,"width":59,"height":60},"https://docshare.wps.com/thumbnails/2025-2026-medicare-prior-authorization-grid-prior-authorization-requirements/216945.png","ImageObject",300,407,{"name":9,"@type":62},"Person",{"url":42,"name":64,"@type":65},"DocShare","Organization","application/pdf","2026-09-11","2026-09-08",true,{"@type":71,"interactionType":72,"userInteractionCount":20},"InteractionCounter",{"@type":73},"ViewAction",{"@type":75,"mainEntity":76},"FAQPage",[77,83,87,91],{"name":78,"@type":79,"acceptedAnswer":80},"哪些服务不需要事先授权？","Question",{"text":81,"@type":82},"不在该授权表所列范围内的服务不需要授权。紧急住院情形也有特定例外规则。","Answer",{"name":84,"@type":79,"acceptedAnswer":85},"HMO/SNP 与 PPO 在门外服务授权要求上有什么区别？",{"text":86,"@type":82},"HMO/SNP 成员对所有门外（out-of-network）服务都需要事先授权；PPO 计划对门外服务不需要事先授权。",{"name":88,"@type":79,"acceptedAnswer":89},"已经完成的服务如果需要追溯授权怎么办？",{"text":90,"@type":82},"追溯请求（已提供的服务）需要作为索赔（claim）提交，而不是走事先授权流程。",{"name":92,"@type":79,"acceptedAnswer":93},"紧急或急诊服务是否需要授权？",{"text":94,"@type":82},"紧急（emergent）住院不要求事先授权，但住院期间需在索赔付款前完成授权；需提交通知以录入授权并进行并行评审。紧急/急需服务通常也不需要事先授权，但需按适当的账单做法在必要时标识为紧急/急需。","https://schema.org",{"og:url":52,"og:type":97,"og:title":13,"og:site_name":64,"og:description":14},"article",{"robots":99,"canonical":52},"index,follow",{"doc_id":7,"site_id":25},{"code":4,"msg":5,"data":102},[103,107,111,115,120,125,128,133,138,141,145],{"id":21,"doc_module":4,"doc_module_name":47,"category_name":104,"show_sort_weight":105,"slug":106},"Story & Novel",90,"story-novel",{"id":20,"doc_module":4,"doc_module_name":47,"category_name":108,"show_sort_weight":109,"slug":110},"Literature",80,"literature",{"id":53,"doc_module":4,"doc_module_name":47,"category_name":112,"show_sort_weight":113,"slug":114},"Exam",70,"exam",{"id":116,"doc_module":4,"doc_module_name":47,"category_name":117,"show_sort_weight":118,"slug":119},5,"Comic",60,"comic",{"id":121,"doc_module":4,"doc_module_name":47,"category_name":122,"show_sort_weight":123,"slug":124},6,"Technology",50,"technology",{"id":11,"doc_module":4,"doc_module_name":47,"category_name":12,"show_sort_weight":126,"slug":127},40,"healthcare",{"id":129,"doc_module":4,"doc_module_name":47,"category_name":130,"show_sort_weight":131,"slug":132},8,"Research & Report",30,"research-report",{"id":134,"doc_module":4,"doc_module_name":47,"category_name":135,"show_sort_weight":136,"slug":137},9,"Religion & Spirituality",20,"religion-spirituality",{"id":136,"doc_module":4,"doc_module_name":47,"category_name":139,"show_sort_weight":136,"slug":140},"World Cup","world-cup",{"id":142,"doc_module":4,"doc_module_name":47,"category_name":143,"show_sort_weight":142,"slug":144},10,"Lifestyle","lifestyle",{"id":146,"doc_module":4,"doc_module_name":47,"category_name":147,"show_sort_weight":116,"slug":148},19,"General","general"]