Prior authorization appeal letter for care your plan won't approve
Updated October 1, 2026 · How we write our guides
When to use it
Use this letter when your health plan won't approve care before you get it. First ask your doctor's office about resending records. If that doesn't work, send this appeal. For most private plans, you have 180 days to appeal, and your plan must decide within 30 days, or 72 hours if urgent.
Your doctor ordered care, and your health plan said no before you got it. This letter asks your plan to review that prior authorization denial. Our guide on what to do when prior authorization is denied walks through every step. It's part of our guide on how to appeal an insurance denial.
When to use this letter
Try a quicker fix first. Ask your doctor's office to send any missing records and request approval again. Ask whether your doctor can talk with the plan's reviewer.
Use this letter when that doesn't work, or when the denial is about medical necessity, coverage, or network status. If the care already happened and the claim was denied, use our insurance appeal letter instead.
Check your deadline first
For most private plans, you have 180 days from getting the denial notice to appeal. Because you haven't gotten the care yet, your plan must decide within 30 days. Our appeal deadline calculator can help you count.
Medicare Advantage and Medicaid plans have their own deadlines and steps. If you have 1 of those, follow the instructions on your notice.
What to fill in
- Reference number and denial reason: on the denial notice. If only your doctor got it, ask their office for a copy.
- What you've already tried: list treatments, tests, or therapy you've had, with rough dates.
- Why you need it now: in plain words, say how the condition affects your daily life.
- The urgent paragraph: keep it only if your doctor believes the normal wait could seriously harm your health. If not, delete the paragraph that starts "Urgent request."
Your letter
Highlighted words are blanks you haven't filled in yet.
What to attach
Send copies, not originals. Include:
- The denial notice
- A letter from your doctor that answers the exact reason your plan gave
- Records that back it up, like test results, visit notes, and proof of treatments you've tried
- The part of your plan documents that covers the care, if you can find it
How to send it
Follow the instructions on your denial notice. Many plans take appeals by mail, by fax, or through an online member portal. For an urgent appeal, use the fastest method your notice lists, and call to confirm it arrived.
- By mail: use certified mail with a return receipt.
- By portal or fax: save the confirmation page or fax receipt.
- Either way: keep a copy of everything, and tell your doctor's office you've appealed.
What happens next
For most private plans, your plan must decide within 30 days, or within 72 hours if your appeal is urgent. Some employer plans have 2 levels of appeal, each with a shorter time limit. Write down the date your plan got your appeal, and call if you don't hear back in time.
If your plan says no again, you can often ask for an independent external review within 4 months. In urgent situations, you can ask for it at the same time as your appeal. Our external review request letter helps you ask.
Common questions
Should I appeal or ask my doctor to resubmit?
Start with your doctor's office. If the denial was about missing records or a wrong code, a new request with the right records is often faster. If your plan still says no, or the denial was about medical necessity or coverage, file an appeal. You can do both, but keep your appeal deadline in mind.
When is a prior authorization appeal urgent?
An appeal is urgent if the normal wait could seriously harm your life, your health, or your ability to regain function. If a doctor who knows your condition tells an employer plan your claim is urgent, the plan must treat it that way. Most private plans must decide urgent appeals within 72 hours.
Can my doctor file the appeal for me?
Often, yes. For urgent care under an employer plan, your treating doctor can act for you without a separate form. In other cases, your plan may need a signed form that lets your doctor or a family member act for you. Call member services to ask what your plan needs.
Sources
- Filing a claim for your health benefits, U.S. Department of Labor, Employee Benefits Security Administration. Accessed October 1, 2026.
- Internal appeals, HealthCare.gov. Accessed October 1, 2026.
- External review, HealthCare.gov. Accessed October 1, 2026.
Related guides
- GuidePrior authorization denied: what to do nextPrior authorization denied? Learn why it happens, how your doctor can resubmit or ask for a peer-to-peer review, and how to appeal before your deadline.
- Start hereHow to appeal a health insurance denialA denied claim isn't the final word. Learn how to appeal an insurance denial, from internal appeal to external review, with deadlines for each plan type.
- GuideInternal appeal vs. external review: which comes whenAn external review lets an outside reviewer decide your health insurance denial. Learn when you can ask, your 4-month deadline, and how the decision works.
This is general information, not legal or medical advice. Rules can depend on your plan and your state. Romi Care isn't an insurer, law firm, collection agency, or government program.