Prior authorization and pre-approval

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An approval is not always a promise to pay. Compare the approval line by line with the claim: the dates, provider, place and codes must match.
Medicare Advantage plans may not deny a service for lack of medical necessity after approving it, except for good cause or reliable evidence of fraud or similar fault.
For employer and Marketplace plans we found no federal rule that bars this, so your proof of approval and your plan document do the work. Some states add protection.

More guides, tools, letters 9

Approved, then denied
What to do when your plan approved a service or said it was covered, then refused to pay the claim. Includes what Medicare Advantage plans may not do.
Preventing the next denial
Steps to take before, during and after care. They make a denial less likely and an appeal stronger. Get approvals in writing, confirm network status and keep records.
Prior authorization denied
What to do when your plan refuses to approve a service before you get it. Also which decision deadlines apply to employer, Marketplace, Medicare Advantage and Medicaid plans.
Prior authorization stuck
What to do when your plan has not answered a prior authorization request, how long each type of plan has, and how to push a stalled request forward.

Tool

Decision clock

Check whether your plan has taken longer than the law allows to decide, and what you can do if it has.

Letter or script

Appeal: approved, then denied

Asks your plan to pay a claim for care it approved in advance, and to explain what changed and which plan provision lets it deny payment after approval.
Letter or script

Appeal: prior authorization denied

Asks your plan to reverse a refusal of approval before care, to say what standard it applied, and to decide with a clinician in the right field.

Denial reason

No prior authorization

The plan says approval was needed before the service and was not obtained. Find out whether approval was really required, who was supposed to ask, and whether getting it was impossible. Your provider often has to act.
Denial reason

Prior authorization denied

Your doctor asked the plan to approve care in advance and the plan said no. The clocks are short, and your doctor can ask for a doctor-to-doctor call. Independent external review is open if the reason is medical and your plan is not grandfathered.

Questions to keep handy

Your notice or plan document controls if it differs from a general rule. Keep a copy of everything and the date and way you sent it.