Prior authorization denied: what to do next

Your doctor ordered a test, a procedure, or a treatment. Then your health plan said no before you even got it. That's a prior authorization denial, and it's often not the final word.

This guide shows what to do when prior authorization is denied, from a quick resubmission to a formal appeal. It's part of our guide on how to appeal an insurance denial.

What is prior authorization?

Prior authorization is your plan's approval of care before you get it. Your plan may also call it preauthorization, precertification, or a pre-service request. Your doctor's office usually sends the request for you.

Which care needs approval depends on your plan. It's often planned care, like some scans, surgeries, or infusions. Your plan documents list what needs approval.

An approval means your plan agrees the care is medically necessary. It isn't a promise to pay. Your plan still checks your coverage, your deductible, and other plan rules when the claim comes in.

Why do prior authorization requests get denied?

The denial should tell you why. Most reasons fall into a few groups:

• Missing records. The request didn't include the notes, test results, or history your plan wanted.
• A step wasn't tried first. Your plan wants you to try a less costly option first, like physical therapy before an MRI.
• Medical necessity. Your plan's reviewer doesn't think you need the care, based on its guidelines.
• Not covered. Your plan says the service isn't a benefit, or calls it experimental.
• Network or setting. The provider or facility isn't in your network, or your plan wants a different setting.
• Paperwork. A wrong code, a wrong member ID, or a request sent to the wrong plan.

Many of these can be fixed with better information. That's why the first steps involve your doctor's office.

Step 1: Read the denial notice

Find the written notice from your plan. Sometimes it goes only to your doctor, so ask their office for a copy. You can also call the member services number on your insurance card.

Look for 4 things:

• The specific reason for the denial
• The plan rule or guideline it's based on
• What information would change the decision, if any
• How to appeal, and your deadline

You can ask your plan for a free copy of any guideline it used. If it says the care isn't medically necessary, you can ask for the clinical reasons behind that.

Step 2: Ask your doctor's office to resubmit

Call your doctor's office and share the reason for the denial. Ask if they can send the missing records and request approval again.

A new request with the right records is often faster than an appeal. It works best when the denial was about missing notes, a skipped step you've actually done, or a wrong code.

Ask the office these questions:

1. What did the plan say was missing?
2. Can you send it and resubmit this week?
3. Can you mark it urgent, if my doctor thinks waiting could harm my health?
4. When should I check back?

Write down the date and the name of the person you spoke with.

Step 3: Ask about a peer-to-peer review

Many plans let your doctor talk with the clinician who reviewed the request. This is often called a peer-to-peer review. Your doctor can explain your history and answer questions on the spot.

The rules vary by plan. Some plans offer it only for a short time after the denial, so ask your doctor's office to request it soon. Don't assume it pauses your appeal deadline. Ask your plan, and keep the deadline in mind.

Step 4: File an internal appeal

If a resubmission or a call doesn't work, file an internal appeal. This asks your plan to take a full, fresh look at its decision.

For most private plans, you have 180 days from getting the denial to appeal. Because you haven't gotten the care yet, your plan must decide within 30 days. If your employer plan has 2 levels of appeal, each level has 15 days.

Your appeal is stronger with:

• A letter from you. Say what was denied and why you need it.
• A letter from your doctor. It should answer the exact reason your plan gave.
• Records. Include test results, notes, and proof of treatments you've already tried.
• Your plan's own words. Quote the part of your plan documents that covers the care.

Our prior authorization appeal letter gives you a place to start. Send your appeal in a way that gives you proof, and keep copies.

Ask for an urgent appeal when waiting could harm you

An appeal is urgent if the normal wait could seriously harm your life, your health, or your ability to regain function. It's also urgent if your doctor says waiting would cause severe pain that can't be managed.

• Most private plans must decide urgent appeals within 72 hours.
• If a doctor who knows your condition tells an employer plan your claim is urgent, the plan must treat it that way.
• For urgent care, a health care professional who knows your condition can act for you.
• You can ask for an urgent external review at the same time as your urgent appeal.

Step 5: Ask for an external review if your plan still says no

If your plan denies your appeal, you can often ask an independent review organization (IRO) to decide. The IRO isn't part of your plan.

You have 4 months after the final denial to ask. A standard review takes up to 45 days, and an urgent one up to 72 hours. If the reviewer sides with you, your plan must accept the decision.

External review covers denials based on medical judgment. That includes medical necessity, the level or setting of care, and whether a treatment is experimental. Our guide to external review for health insurance explains which comes when.

Say Linda's doctor wants an MRI of her lower back. Linda has a fully insured plan through work, with 1 level of internal appeal. Here's how her timeline could look.

Date	What happened	The rule behind it
April 1, 2026	Her doctor's office sent the prior authorization request.	Her plan had up to 15 days to decide, until April 16.
April 9	The denial arrived. It said her records didn't show 6 weeks of physical therapy.	Her 180 days to appeal began. Her deadline was October 6.
April 10	Her doctor asked for a peer-to-peer review. The plan's reviewer still wanted the therapy notes.	Linda kept her October 6 deadline in mind.
April 14	Linda filed an appeal with her doctor's letter and notes from 8 weeks of physical therapy.	Her plan had 30 days to decide, until May 14.
May 6	Her plan approved the MRI.	No external review was needed.

Her doctor said a few weeks' wait was safe for her, so Linda appealed before she scheduled the scan. The fix was a record her plan never had.

What's different with Medicare Advantage?

If you have a Medicare Advantage plan, its decision on a prior authorization request is called an organization determination.

Here's what's different at a high level:

• Faster first decisions. Since January 1, 2026, plans must decide most standard requests within 7 calendar days. Fast requests take up to 72 hours.
• A late answer counts as a denial. If your plan misses its deadline, you can appeal.
• A shorter appeal window. You have 65 days from the date on the notice to ask for a reconsideration. Your plan must decide within 30 days, or 72 hours if it's fast.
• Automatic outside review. If your plan still says no, even in part, it must send your case to an independent review entity. You don't have to ask.
• Approvals stick. Once your plan approves care ahead of time, it generally can't deny it later as not medically necessary.

Our guide to a Medicare Advantage denial appeal covers every level. If you have Medicaid, see our guide to a Medicaid fair hearing.

What changed in 2026: the federal prior authorization rule

In 2024, the Centers for Medicare & Medicaid Services (CMS) finalized the Interoperability and Prior Authorization final rule, called CMS-0057-F. Its first parts took effect in 2026. It covers Medicare Advantage, Medicaid, the Children's Health Insurance Program (CHIP), and Marketplace plans on HealthCare.gov.

Medicaid and CHIP managed care plans had to start with their first contract period beginning on or after January 1, 2026. Plans can sometimes extend these deadlines, for example when they need more records.

A few more things to know:

• The rule doesn't apply to drugs. Prescription drug requests follow other rules.
• Plans must post their numbers. Starting in 2026, covered plans must post yearly prior authorization data on their websites by March 31. It includes how often they approve requests after an appeal.
• Electronic requests come next. By 2027, covered plans must support electronic prior authorization requests.

The specific reason is the key part for you. It tells your doctor exactly what to fix or send.

Should you get the care before it's approved?

That's a decision to make with your doctor. Your health comes first, and a denial doesn't stop you from getting care.

If your doctor says you shouldn't wait, ask for an urgent decision. If you go ahead before approval, ask the provider these questions first:

• What will the care cost if my plan doesn't pay?
• Can I get a written estimate?
• Do you offer a self-pay discount or a payment plan?
• Will you hold the bill while I appeal?

Emergency care is different. Federal rules don't let most private plans require prior authorization for emergency services. If you think you have an emergency, get care right away.

If this doesn't work

If your appeal and external review don't change the answer, you still have options:

• Ask about another treatment. Your plan may cover a different test or drug that your doctor thinks will work.
• Ask about a different setting. An outpatient center may be approved when a hospital isn't.
• Check for an in-network provider. A network problem can sometimes be fixed by switching.
• Ask about cost help. If you get the care anyway, the provider may offer a payment plan or charity care.
• Keep your records. If the care is later billed, you'll want the full paper trail.

If a claim for the care is denied after you get it, see what to do when insurance didn't pay a medical bill. Our guide to claim denial codes explained covers code 197, which means prior authorization was missing.

When to get help

You can often handle a prior authorization denial with your doctor's office. It's worth getting help when:

• The care is costly or ongoing, like cancer treatment or infusions.
• Your plan keeps asking for more records.
• Your plan missed its deadline or didn't answer.
• You're handling this for someone else and you're short on time.

Start with your insurer's member services number on your card. Your denial notice should list your state's consumer assistance office, if it has one. Your state insurance department can also help with fully insured and Marketplace plans.

For employer plans, the Department of Labor's Employee Benefits Security Administration answers questions at 1-866-444-3272. For Medicare, call 1-800-MEDICARE (1-800-633-4227), or get free counseling from your State Health Insurance Assistance Program.

If you have a serious illness, Patient Advocate Foundation, a nonprofit, offers free case management that can include appeals. A medical bill advocate can also make the calls. Our hubs on cancer treatment bills and MRI and CT scan denials cover those denials in more depth.