Prior authorization denied

A prior authorization denial means your plan refused to approve a service, drug or stay before you received it. No claim for the care may exist yet, so you can often act before any bill arrives. Your doctor’s office usually sent the request, so it is usually the first place to look. You can appeal on your own as well.

What this means

Prior authorization (also called prior approval or pre-certification) is the plan’s advance decision that it will cover a service. For employer plans and for individual and Marketplace plans that are not grandfathered, the federal claims rule treats a prior authorization request as a “pre-service claim”. A denial of that request is a denial you can appeal, with the same rights as any other denial.

The deadlines for the plan’s decision depend on your coverage:

• Employer plans (job-based) and individual or Marketplace plans: the plan must decide an urgent request as soon as possible and within 72 hours. It must decide a non-urgent request within 15 days. It may extend a non-urgent request once, by up to 15 days, for reasons beyond its control, if it tells you before the first period ends.
• Medicare Advantage: since 1 January 2026, the plan has 7 calendar days for items and services that need prior authorization, and 72 hours for an expedited request. Drugs given in a doctor’s office (Part B drugs) have 72 hours standard and 24 hours expedited.
• Medicaid and the Children’s Health Insurance Program (CHIP): for state fee-for-service programs from 1 January 2026, 7 calendar days standard (which can be extended by up to 14 days) and 72 hours expedited. For Medicaid managed care plans the 7-day rule starts with each plan’s contract year that begins on or after 1 January 2026, so the start date differs by state. These deadlines leave out drugs.

The 72-hour and 7-day deadlines in the new federal prior authorization rule (called CMS-0057-F) do not cover employer plans. They do not cover Marketplace plans either. A federal proposal from April 2026 would extend them to plans on the federal Marketplace from October 2027, but as of 11 November 2026 it is only a proposal and is not in force. Check the date on your notice, which controls.

What to do

1. Read the denial notice for the specific reason. It must name the reason and the plan rule it relied on. The denial letter checklist shows what to look for. (You.)
2. Ask your doctor’s office what was sent and what was missing. Many prior authorization denials come from a missing note, test result or code. A corrected request is sometimes faster than an appeal. (Your doctor’s office.)
3. Ask your doctor to request a peer-to-peer call. This is a phone call between your doctor and the plan’s reviewing physician. (Your doctor.)
4. Ask the plan for the clinical criteria it used. Use the clinical criteria request letter. The plan must give you, free of charge, a copy of any internal rule or guideline it relied on. (You.)
5. If waiting could harm you, ask for an urgent appeal. If a physician who knows your condition says the claim is urgent, an employer plan must treat it as urgent. A non-grandfathered plan or insurer must defer to your treating provider’s view. (Your doctor certifies; you or your doctor files.)
6. File the appeal before your deadline. Employer plans and non-grandfathered individual plans must give you at least 180 days after you receive the denial notice. Medicare Advantage gives 65 days from the date on the notice. A Medicaid plan gives 60 days from the date on the notice. Your plan may allow more. (You, or your doctor with your permission.)
7. If the final appeal is denied and the reason is medical judgment, request external review. You have at least four months after the final denial. See external review for the steps.

What the plan may say, and what to say back

“We did not receive your request.” If the request reached the plan unit that handles benefits and named you, your condition and the treatment, the plan must tell you the correct way to submit within 5 days (24 hours if urgent). Ask for that in writing.

“You did not get approval first.” A plan cannot deny a claim for lack of approval where getting approval was impossible or could have seriously jeopardized life or health. Emergency services cannot be made subject to prior authorization.

The rule

For employer plans and non-grandfathered individual and Marketplace plans, a prior authorization request is a pre-service claim: 72 hours if urgent, 15 days if not (with one 15-day extension), and appeals decided in 72 hours or 30 days. 29 Code of Federal Regulations (CFR) 2560.503-1

Watch for

• Specific reasons. Since 1 January 2026, Medicare Advantage plans and issuers on the federal Marketplace must give the provider a specific reason when they deny a non-drug prior authorization request. This helps your doctor write the response.
• State law. Many states set their own prior authorization rules for insured plans. For example, the Washington page and the Colorado page list rules. State rules do not reach self-funded employer plans, whose complaints go to the federal Department of Labor. See Washington and Colorado.
• Promises are not rights. In June 2025 major insurers made a voluntary pledge to reduce and speed up prior authorization. It is a pledge, not a rule, and it gives you no enforceable right.
• Original Medicare. It mostly does not use prior authorization. A pilot program that began on 1 January 2026 does in six states: New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington. If your notice mentions it, follow the appeal steps on the notice.

What next

• Prior authorization stuck: if the plan has not answered at all.
• Approved, then denied: if the plan approved the care and then refused to pay.
• File an internal appeal: the steps for the first appeal.
• Prior authorization topic page: every guide, letter and tool on this subject.