What Is Prior Authorization and How Do You Get Through It
Last updated September 10, 2026.
Prior authorization is a process where your health insurer must approve a treatment, test, or medication before you receive it. It exists to control costs and verify medical necessity, but it can delay care by days or weeks. Most requests go through your doctor's office, and you have clear appeal rights if the insurer says no.
Why insurers require prior authorization
Health plans use prior authorization to decide whether a service is medically necessary and covered under your policy. The insurer reviews your case before paying for expensive tests, specialist procedures, brand-name drugs, or advanced imaging like MRI scans.
The process aims to prevent overuse of costly treatments and steer patients toward lower-cost alternatives when clinically appropriate. A 2023 survey by the American Medical Association found that 94 percent of physicians report care delays due to prior authorization, and 80 percent say it sometimes leads patients to abandon treatment.
Common items requiring prior authorization include specialty medications, durable medical equipment like wheelchairs, surgery, physical therapy beyond a set number of visits, and certain diagnostic imaging. Urgent or emergency care typically bypasses prior authorization, but what counts as urgent varies by plan.
How long prior authorization takes
Federal rules under Medicare Advantage require insurers to decide standard requests within 14 calendar days and urgent requests within 72 hours. Most private insurers follow similar timelines, though exact windows depend on your state and plan.
In practice, straightforward requests for common medications or tests may clear in two to five business days. Complex cases involving multiple doctors or rare conditions can stretch to two weeks or longer. Your doctor's office usually submits the request electronically or by fax, and the insurer either approves, denies, or asks for more clinical records.
You can check the status by calling the member services number on your insurance card and asking for the prior authorization department. Have your reference or case number ready if your doctor provided one. Some insurers also show pending authorizations in their online member portals.
What to do when prior authorization stalls
If you have not heard back within the insurer's stated timeline, call member services and ask why. Common causes include missing clinical notes from your doctor, incorrect billing codes, or the request sitting in a queue for a medical reviewer.
Ask your doctor's office to follow up as well. They can submit additional documentation, correct errors, or request an expedited review if your condition is urgent. Under federal law, Medicare Advantage plans must offer expedited reviews when a standard timeline could seriously harm your health, and many state laws extend this right to private plans.
If the delay is causing real harm, document the timeline and any worsening symptoms. You may file a complaint with your state insurance department or, for employer plans, contact the Department of Labor. Links to state departments are listed at usa.gov. For immediate urgent needs, your doctor may proceed with treatment and appeal the payment denial later.
Your rights when prior authorization is denied
A denial letter must explain why the insurer said no and outline your appeal rights. Common reasons include the service being experimental, not medically necessary by the plan's standards, or available through a less expensive alternative.
You have the right to an internal appeal, where the insurer reviews the decision again. Most plans require you to file within 180 days of the denial. Your doctor can submit a letter explaining why the treatment is necessary, citing clinical guidelines or studies. For urgent cases, the insurer must decide an expedited appeal within 72 hours.
If the internal appeal fails, you can request an external review by an independent organization. This is free under federal law for most plans. The external reviewer's decision is binding on the insurer in many cases. Medicare Advantage and Marketplace plans must offer external review, and most employer plans do as well under the Affordable Care Act.
Keep copies of all denial letters, appeal forms, and doctor notes. If you need help navigating the process, your state insurance department often has a consumer assistance program. You can also contact a local legal aid office if the denial threatens serious health consequences.
Practical steps to speed up the process
Before scheduling a service that typically requires authorization, ask your doctor's office if they will handle the request or if you need to call your insurer. Most offices submit requests as part of routine care, but some specialty services fall on the patient.
Confirm your insurer has your current contact information so they can reach you if they need more details. Respond quickly to any requests for additional records or clarification. Delays often happen because a letter sits unopened or a voicemail goes unanswered.
If your doctor prescribes a brand-name drug requiring authorization, ask if a covered generic exists or if they can submit a formulary exception request. Some plans approve drugs faster if the doctor explains why generics failed or are contraindicated. Manufacturer coupon programs may cover out-of-pocket costs while you wait, though they do not replace insurance approval.
When prior authorization does not apply
Emergency services never require prior authorization under federal law. If you go to an ER for a true emergency, the hospital will treat you and bill your insurer afterward. The insurer cannot deny payment because you did not get approval first.
Preventive services covered at no cost under the Affordable Care Act, such as annual checkups, mammograms, and colonoscopies at recommended ages, also do not require authorization. Double-check your plan's summary of benefits if you are unsure whether a service counts as preventive.
Some plans waive prior authorization for certain in-network providers or for continuity of care when you switch plans mid-treatment. Review your plan documents or call member services to confirm. If prior authorization is creating a barrier to necessary care, a free text consult with an AI doctor can help you understand your options and what to ask your insurer or provider, though it does not replace the formal authorization process.
Common questions
How do I know if my treatment needs prior authorization?
Check your plan's summary of benefits or call the member services number on your insurance card. Your doctor's office usually knows which services require approval and will tell you before scheduling. Common items include specialty drugs, MRI or CT scans, surgeries, and durable medical equipment.
Can I start treatment while waiting for prior authorization?
You can, but your insurer may not pay for it if the authorization is later denied. If your condition is urgent, ask your doctor to request an expedited review or proceed with treatment and appeal any denial afterward. For true emergencies, go to the ER without waiting for approval.
What happens if my prior authorization is denied?
You can appeal the decision. File an internal appeal with your insurer, usually within 180 days. Your doctor can submit supporting records. If that fails, you can request a free external review by an independent organization, whose decision is often binding on the insurer.
How long does an appeal take after a prior authorization denial?
Standard appeals take up to 30 days for most plans. Expedited appeals for urgent situations must be decided within 72 hours under federal rules for Medicare Advantage and many state laws for private plans. External reviews typically conclude within 60 days, or four days if expedited.
Does prior authorization cost me money?
The authorization process itself is free. You do not pay for the insurer's review. However, if authorization is denied and you proceed with treatment anyway, you may owe the full cost out of pocket. If approved, you pay your normal copay, coinsurance, or deductible.
Sources
- CMS - Medicare Advantage and Part D Coverage Determinations
- Healthcare.gov - Health Insurance Rights and Protections
- USA.gov - State Health Insurance Assistance
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