Updated October 15, 2026
What is prior authorization? Prior authorization is approval your health plan must give before it will cover certain medications, tests, or procedures. Your doctor’s office usually submits the request. Starting in 2026, Medicare Advantage, Medicaid, and CHIP plans must decide urgent requests within 72 hours and standard requests within 7 calendar days, and they must explain any denial. Your plan can’t require prior authorization for emergency care.
Prior authorization can be a frustrating hurdle, whether you’re filling a prescription or scheduling a procedure. Your plan won’t pay for the treatment until it’s approved, and the process can take time. Knowing how it works, how long it should take, and what to do if you’re denied can help you avoid delays and protect your access to care.
Key Takeaways
- Prior authorization means your plan must approve certain medications or treatments before it covers them.
- Your provider usually submits the request, but you can follow up and help move it along.
- A federal rule now sets decision deadlines for Medicare Advantage, Medicaid, and CHIP plans and requires a specific reason for every denial.
- Many insurers have pledged to honor your existing approvals for 90 days when you switch plans.
- Appeals often succeed. Most appealed Medicare Advantage denials are overturned.
What Is Prior Authorization?
Prior authorization, also called preauthorization, preapproval, or precertification, is a process in which your provider must get approval from your health plan before the plan will cover a prescribed medication, procedure, or treatment. Without it, your plan may deny the claim.
Supporters say prior authorization helps prevent unnecessary or unsafe care and keeps costs down. Physician groups, including the American Medical Association, say it often delays care and adds paperwork, and they have pushed for reforms to streamline it.
Why Health Plans Require Prior Authorization
Most health plans, including many Medicare Advantage plans, use prior authorization to:
- Check safety: Some drugs and procedures carry serious risks, so plans want to confirm they’re the right choice for your condition.
- Confirm the treatment fits plan guidelines: Some treatments are covered only after you’ve tried other options first, a process called step therapy.
- Control costs: Plans want to avoid paying for expensive care when an equally effective, lower-cost option exists.
For example, if you’re prescribed a high-cost biologic for arthritis, your plan might require proof that you’ve tried other medications first.
When Prior Authorization Is Usually Required
Every plan is different, but prior authorization is commonly required for:
- Specialty medications: High-cost drugs for conditions like cancer, multiple sclerosis, or rheumatoid arthritis.
- Brand-name drugs when a lower-cost generic is available.
- Medications with safety concerns that need close monitoring.
- Imaging and procedures: MRIs, CT scans, and many planned surgeries.
Check your plan’s formulary or benefits guide to see what needs approval. Our guide to prescription benefits explains formularies and drug tiers.
How the Prior Authorization Process Works
- Your provider submits a request. Your doctor, specialist, or pharmacist sends your plan information explaining why you need the treatment.
- Your plan reviews it. The plan compares your medical information with its coverage guidelines.
- Your plan makes a decision. If approved, the treatment is covered under your plan’s normal cost-sharing. If denied, the plan must tell you why.
- You or your provider can appeal. If the request is denied, you can submit more information and ask the plan to reconsider.
How Long Does Prior Authorization Take?
It depends on your plan and the request.
- Medicare Advantage, Medicaid, and CHIP: Since January 1, 2026, these plans must decide urgent requests within 72 hours and standard requests within 7 calendar days for medical items and services (CMS). Those deadlines don’t apply to prescription drug requests.
- Employer and Marketplace plans: The federal deadlines above don’t apply. Many routine requests take several business days, and urgent requests are often decided within 72 hours. Ask your plan for its timelines.
If your request is taking too long, call your provider’s office or your plan to check the status, and ask for an expedited review if waiting could harm your health.
What’s New in 2026
- Clear reasons for denials: Medicare Advantage, Medicaid, and CHIP plans must give a specific reason when they deny a request.
- Public reporting: These plans must publicly report prior authorization data, such as approval and denial rates and average decision times.
- Insurer commitments: Many major insurers pledged to reduce the number of services that need prior authorization. Starting in 2026, they’ll honor your existing approvals for comparable in-network care for 90 days when you switch plans, and by 2027 they expect to answer at least 80% of electronic requests in real time (MedCity News).
What to Do If Your Prior Authorization Is Denied
A denial doesn’t always mean you can’t get your treatment. You have options:
- Read the denial letter. It should explain why the request was denied and how to appeal.
- Talk with your provider. They may be able to fix a coding error, add missing information, or request a peer-to-peer review with the plan’s doctor.
- File an appeal. If you believe the denial is wrong, ask for a formal review. If your internal appeal is denied, you may be able to request an independent external review. See our guide to appealing a denied claim.
- Ask about alternatives. Your provider may be able to suggest a different treatment that doesn’t need approval.
Appeals are often worth it. In 2024, Medicare Advantage insurers denied 7.7% of nearly 53 million prior authorization requests. Only 11.5% of those denials were appealed, and more than 80% of appeals were partly or fully overturned (KFF).
How to Avoid Prior Authorization Delays
- Ask early. Before starting a new medication or scheduling a procedure, ask whether it needs prior authorization and who will submit it.
- Make sure the request is complete. Missing test results or records are a common cause of delays.
- Follow up. Check the status with your provider’s office or your plan’s member portal.
- Plan ahead for renewals. Many approvals expire. If you take a long-term medication, start the renewal before your supply runs out.
- Tell your new plan about approvals when you switch. Ask whether it will honor your current authorizations during the transition.
Prior Authorization and the No Surprises Act
The No Surprises Act mainly protects you from surprise out-of-network bills. Its key rule for prior authorization is simple: your plan can’t require prior authorization for emergency care, and emergency care must be covered at in-network cost-sharing even at an out-of-network hospital. Learn more in What Is the No Surprises Act?
Frequently Asked Questions
What does prior authorization mean?
It’s an approval your health plan must give before it will cover a specific medication, test, or procedure.
Who is responsible for getting prior authorization?
Your doctor, other provider, or pharmacist usually submits the request. You may need to follow up with your plan or provide more information.
How long does prior authorization take?
Medicare Advantage, Medicaid, and CHIP plans must decide within 72 hours for urgent requests and 7 calendar days for standard requests. Other plans set their own timelines, often several business days for routine requests.
Do I need prior authorization for emergency care?
No. Under the No Surprises Act, health plans can’t require prior authorization for emergency services.
What happens if my prior authorization is denied?
Your plan must explain why. You and your provider can submit more information, request a peer-to-peer review, or file an appeal. Many appeals succeed.
Does my prior authorization carry over if I switch plans?
It may. Many insurers have committed to honoring existing approvals for comparable in-network care for 90 days after you switch. Ask your new plan how it handles transitions.
Learn More with Patient.com
Prior authorization can feel like one more hurdle between you and your care. Patient.com breaks down how it works and what your options are, so you can work with your providers and your plan to get the care you need.
