Prior authorization denied: what does it mean and what do I do next?
A prior-authorization denial means the plan refused to approve the service before it happens, usually because the request did not meet the plan's written criteria or the plan says more information is missing. Ask for the criteria, get the ordering clinician to answer each unmet point, and file the appeal before the date on the notice.
What to do, in order
- Step 1
Find the exact reason
The denial should say whether the issue is medical necessity, missing records, step therapy, site of care, network status, or plan exclusion. Do not appeal a missing-record denial as if it were a clinical denial.
- Step 2
Ask for the criteria and reviewer information
Request the internal rule, guideline, protocol, and reviewer specialty relied on. For employer and ACA plans, relevant claim documents must be provided free on request.
- Step 3
Have the clinician answer the criteria
The strongest appeal is a short letter from the ordering clinician that quotes the unmet criteria and points to the chart notes, test results, failed conservative care, or contraindications that satisfy them.
- Step 4
Request expedited handling if waiting is unsafe
If delay could seriously jeopardize health or the ability to regain function, ask for an urgent appeal and state why in medical terms.
The deadline that applies
Employer and ACA plans give at least 180 days to file the appeal after the denial, but pre-service appeals are usually decided within 30 days and urgent appeals within 72 hours (29 CFR 2560.503-1; 45 CFR 147.136). CMS-0057-F also tightens many prior-authorization decision timeframes for affected payers beginning in 2026.
Calculate your date →Documents to gather
- The denial letter or Explanation of Benefits, every page
- Your insurance card and the plan's benefit document
- The clinical records and test results that support the service
- The plan's written criteria or policy, if you have it
- The prior-authorization request form and any plan response
- The ordering clinician's letter mapped to the criteria
Go deeper
Related questions
Does a prior-authorization denial mean the treatment is not covered?
Not always. It may mean the plan needs more information, wants a different site of care, or says a criterion was not met. A true benefit exclusion is harder and needs a different argument.
Should my doctor do a peer-to-peer first?
Often yes, but do not let the appeal deadline pass. A peer-to-peer can help, but the written appeal preserves rights and creates the record.
Can I appeal before the service happens?
Yes. A pre-service denial is appealable, and that is usually the best time to fix it.
Sources
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