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Prior authorization denied: what to do

Prior authorization (pre-approval) denials are "pre-service claims." They have their own timelines and a few extra tools.

Steps

1. Call your provider's office first. Ask for the person who handles authorizations or appeals. They may already be working on it.
2. Ask for a peer-to-peer review. Your doctor can ask to speak by phone with a physician reviewer at the plan during the appeals process.
3. Act fast. Appeal as soon as you can; an advocate quoted by NBC News recommends filing at least four weeks before the deadline, especially by mail.
4. Check urgency. If a physician says waiting could seriously jeopardize your health, the plan must treat a group-health pre-service claim as urgent: decision within 72 hours.
5. Use the letter. Prior authorization appeal or expedited request.

Timelines for group health plans (federal rules)

Pre-service initial decision: up to 15 days (with possible extension); pre-service appeal decision: no more than 30 days after the plan receives the appeal; urgent appeals: no more than 72 hours. If the plan has two appeal levels, each is generally half the time.

A July KFF poll reported by NBC News found nearly half of insured adults who got a prior authorization denial in the previous two years said the appeals process was somewhat or very difficult.

Related guides

• Prescription drug denied or not covered: exceptions and appeals
• How to file a health insurance internal appeal
• Mental health or substance use care denied: parity and appeals
• State insurance department directory