Ask Proactive – Do we need to obtain prior authorization for every managed care resident who requires skilled services, even if they clearly meet criteria?

Q:

Do we need to obtain prior authorization for every managed care resident who requires skilled services, even if they clearly meet criteria?

Unfortunately, yes — at least for now. Most managed care plans (including Medicare Advantage) still require prior authorization before approving and paying for skilled nursing services, even when the resident obviously meets Medicare criteria.

Managed care works differently than traditional Medicare. Each plan has its own policies, timelines, and documentation hoops to jump through. Even when clinical need is clear, payment depends on properly following the plan’s authorization process.

The good news? Starting in 2026–2027, reforms from CMS and commitments from insurers aim to reduce the number of services needing prior authorization and to make the process faster and more transparent — including real-time decisions and approvals that carry over if a resident switches plans.

Best Practices for Success (for now)

• • Act quickly: Submit the PA request as soon as skilled services are identified.
  • Verify the process: Use the correct portal, phone number, and forms for the specific plan.
  • Document thoroughly: Record both the request and the plan’s response in the resident’s medical record.
  • Follow up: If delayed or denied, appeal promptly with supporting documentation.
  • Be prepared: Create a quick-reference guide listing major plans’ PA processes to help your team act fast and accurately.

What’s Changing?

Between now and 2027, CMS and insurers are rolling out reforms to:

• • Reduce the number of services requiring prior authorization.
  • Honor existing approvals when residents switch plans.
  • Provide real-time decisions.
  • Require a clinician to review all denials.
  • Modernize the process with electronic submissions and clearer appeals.

Until these changes take full effect, stay proactive, and keep following each plan’s current rules to avoid delays or denials.

Next Steps:

• • Register to join us July 23, 2025 for the webinar Medicare Advantage and Managed Care—Challenges, Compliance & Reimbursement Strategies—part of the Capturing Accurate Reimbursement series.
  • Access Proactive support for both Traditional Medicare and Managed Care Medical Review—including ADRs and Appeals. Contact us for expert Medical Review support.

Written By:

Sarah Becker, RN, RAC-CT, DNS-CT, QCP

Director of Clinical Reimbursement

Proactive LTC Consulting