Overview
Medicare Advantage (MA) plans must cover all services that Original Medicare covers, but they can add prior authorization requirements and use different networks. Coverage details vary by plan and carrier. Use Medicare.gov Plan Finder and the carrier's provider portal to verify specific plan benefits.
Key Requirements
- All MA plans must cover Original Medicare services (Parts A and B).
- MA plans can add supplemental benefits: dental, vision, hearing, fitness.
- Prior auth requirements vary by plan. Not required for emergency or urgently needed services.
- CMS requires MA plans to respond to standard PA within 7 days, expedited within 72 hours (effective January 2026).
- Verify plan-specific benefits on medicare.gov or the carrier's provider portal.
Timeline
Before service: Verify MA plan benefits on carrier portal. Check PA requirements. Day of service: confirm active enrollment. After service: submit claim to the MA plan, not to Original Medicare. If denied: appeal within 60 days for organization determination.
Common Denials
| CARC Code | Reason | Primary Cause | Fix |
|---|---|---|---|
| CO-50 | Non-covered service | Service not in MA plan benefits | Verify plan-specific coverage |
| CO-197 | Precertification absent | PA required by MA plan | Check plan's PA list |
| CO-11 | Medical necessity | Plan clinical criteria not met | Include documentation meeting CMS/plan criteria |
Appeals
MA plan denials follow CMS rules. Request a reconsideration within 60 days of the initial organization determination. If denied: appeal to Independent Review Entity (IRE). Then: ALJ hearing if amount exceeds $190 (2026 threshold). CMS response timelines: 7 days standard, 72 hours expedited.
FAQ
How do I verify what a Medicare Advantage plan covers?
Check the plan's Evidence of Coverage (EOC) on the carrier's website, or use Medicare.gov Plan Finder. Enter the member's zip code and plan name to see covered services, copays, and PA requirements.
Do all Medicare Advantage plans cover the same services?
All MA plans must cover everything Original Medicare covers. Differences are in supplemental benefits (dental, vision, fitness), prior auth requirements, network restrictions, and cost-sharing amounts.
Where do I submit claims for Medicare Advantage patients?
Submit claims directly to the MA plan, not to Original Medicare. The MA plan's payer ID is on the member's insurance card. Use the carrier's EDI payer ID for electronic submission.
Prevent These Denials
Altair verifies Medicare Advantage plan-specific coverage and PA requirements before every claim.