My prior authorization was denied. What now?

What is a prior authorization and why was mine denied?

A prior authorization is approval your health plan may require before you get a service or fill a prescription, so that the plan covers it. If your plan says no, it has to tell you why and how you can dispute the decision.

The reason is written in your denial letter. Common reasons include that the plan says the service is not medically necessary, is not a covered benefit, or is from a provider outside the plan's network. Read that letter first, because everything else depends on it. Rules differ by plan type, including Medicare, Medicaid, and separate dental plans, so your own letter and plan papers are the final word. This is general information, not legal or medical advice, and we are not lawyers.

My prior authorization was denied. What do I do first?

Take a breath. A first denial is a step, not the end. Here is a simple order to follow.

• Step 1: Read the denial letter. Find the reason for the denial, the date on the letter, and the deadline to appeal. Your plan has to tell you how to dispute the decision.
• Step 2: Call your doctor's office. Ask them for a letter explaining why you need the treatment. You can send a letter from your doctor with your appeal.
• Step 3: File an internal appeal. Use your plan's forms, or write a letter with your name, claim number, and health insurance ID number. Keep copies of everything and notes of every phone call: the day, time, name of the person, and what was said. Your state's Consumer Assistance Program can file an appeal for you.
• Step 4: Ask for outside review if the plan says no again. For many kinds of denials, such as ones about medical judgment or treatment the plan calls experimental, an independent reviewer can look at the case, and your insurer is required by law to accept that decision.

How long do I have to appeal a denied prior authorization?

Under the private health insurance rules described on HealthCare.gov, you must file your internal appeal within 180 days (6 months) of getting notice that your request was denied. Do not wait. Medicare, Medicaid, and some other plans have their own deadlines, so check the date and deadline printed on your own letter.

If the plan still says no, you can ask for external review. Under the same rules, you must file a written request within 4 months after you receive the plan's final denial notice.

Can I get a fast appeal if I can't wait for treatment?

Yes. If your case is urgent, your insurance company must speed up the process. You can ask for an expedited appeal if the normal timeline would seriously put your life or your ability to regain maximum function at risk. It helps to have your doctor explain this in writing, and to use the word urgent or expedited when you file.

For an urgent internal appeal, the final decision must come as quickly as your medical condition requires, and at least within 4 business days after your request is received. In urgent cases, you can ask for an external review at the same time as your internal appeal. An expedited external review is decided no later than 72 hours after the request is received, or sooner depending on how urgent the case is.

What is an external review, and does it cost anything?

An external review is when an independent third party, not your insurance company, looks at the denial. It either upholds the insurer's decision or decides in your favor, and your insurer is required by law to accept the result. It covers denials that involve medical judgment, denials of treatment the plan calls experimental or investigational, and some coverage cancellations.

If your insurer uses the HHS-administered federal external review process, there is no charge. If it uses a state process or a contracted review organization, you may be charged, but no more than $25 per external review.

How long will the appeal take?

Under the private health insurance rules described on HealthCare.gov, an internal appeal must be finished within 30 days when it is for a service you have not received yet. A standard external review is decided no later than 45 days after the request is received.

Medicare and other plan types can follow different timelines. Your denial letter and plan papers are the final word for your plan.

I have Medicare or Medicare Advantage. Do the same rules apply?

Not exactly. Medicare has its own appeals process, and it varies by the kind of coverage you have. If you are in a Medicare Advantage plan, the plan must tell you in writing how to appeal. Generally there are 5 levels of appeal, and at each level you get a decision letter with instructions for the next step. A State Health Insurance Assistance Program (SHIP) gives free, personal counseling; find yours at shiphelp.org.

Your checklist

• Find the reason and the appeal deadline on your denial letter
• Write down the date on the letter and the day it arrived
• Ask your doctor's office for a letter saying why you need this care
• Say urgent or expedited if waiting could seriously harm your health
• File your appeal in writing and keep a copy
• Keep notes of every call: date, time, name, what was said
• Ask for outside review if your plan says no again

A letter you can copy

[Date] [Insurance company name] Attn: Appeals Department [Address from your denial letter] Re: Appeal of denied prior authorization Name: [Your full name] Member ID: [Health insurance ID number] Claim or reference number: [Number from denial letter] Date of denial letter: [Date] Service or medication denied: [Name of treatment] To the Appeals Department: I am appealing your decision to deny prior authorization for [treatment]. Your letter says the reason was: [reason from letter]. I believe this treatment is needed because [short reason]. My doctor, [doctor name], has provided the enclosed letter supporting this request. [Optional, if urgent: I am asking for an expedited appeal because waiting could seriously harm my health. My doctor's statement is enclosed.] Please review this decision and send your answer in writing to the address above. Sincerely, [Your name] [Phone number] Enclosed: denial letter, doctor's letter, [other documents]

Which rules apply to you?

The steps and deadlines on this page can differ by the kind of plan you have. Your own denial letter always comes first.

• Coverage through a job:ask your HR team whether the plan is “self-funded” or “fully insured.” It can change who you can ask for help. Most private-sector job plans fall under a federal law called ERISA, and the U.S. Department of Labor’s EBSA takes health plan questions at Ask EBSA or 1-866-444-3272.
• Marketplace plan: follow the appeal steps at HealthCare.gov.
• Medicare or Medicaid: each has its own appeal process, listed on your notice.
• Dental-only plan: your plan contract sets the appeal rights, so read it and your letter.

Related answers

• Denied as "experimental or investigational"? Here is what it means and how to push back.
• Denied because of a pre-existing condition
• How to read an insurance denial letter
• How to write an insurance appeal letter
• All answers

Free tools for the next step

Keep your appeal papers in one place. Take a photo of your denial letter, EOBs and insurance cards with GetPreCare, so they are on your phone when the insurer or the office asks. Free. Open GetPreCare. Helping a parent or partner? Set it up for them.

Waiting on a dentist's report before treatment? iReferral tracks the request between your care team and your dentist so it does not get lost. Free. See how it works.