US · guidance
CMS Pub. 100-16, ch. mc86c16a, § 90.2
Prior Authorization
PFFS plans can perform retrospective review of claims for the purpose of verifying
medical necessity and that the service furnished is a covered service. However, PFFS
plans may not require members or providers to obtain prior authorization from the plan as
a condition of coverage. Prior authorization occurs when a plan requires its members or
their providers to seek approval from the plan before the member receives a service from
the provider as a condition of coverage. However, as described below both enrollees and
providers are entitled to request and receive an advance determination of coverage if they
want to ensure that a particular service will be covered by the PFFS plan as described
below under section 100.
History
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
5aa39db7ee9d0da61c8dfc672f3a6529fdcf95e6065c178fbd7a663ac883ddcf
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