Prior Authorization: What It Is, Why It Can Delay Care, and What You Can Do

Your clinician recommends a medication, test, treatment, or procedure. Before the health plan will cover it, the plan requires information and makes an advance coverage determination — prior authorization. The rules governing that process are not uniform: deadlines, review requirements, appeal rights, and outside-review options all depend on the plan type, whether the request concerns a drug or a medical service, urgency, and which regulator has jurisdiction. This guide works through that variation rather than flattening it into one universal timeline.

Prior authorization can delay care, but the rules are not uniform. Deadlines, review requirements, appeal rights, and outside-review options depend on the type of health plan; whether the request concerns a drug or a medical item or service; whether the request is urgent; whether the plan is regulated by Medicare, Medicaid, federal employee-benefit law, California law, or another state's law; and the exact reason for any denial.

The most useful first steps are therefore to identify the plan type, obtain the exact reason for the decision, preserve every deadline, and determine whether the request needs additional documentation, reconsideration, a formal appeal, or urgent regulatory assistance. None of the categories in this guide are exotic or rare — step therapy, network status, formulary tiering, and medical-necessity review between them account for the overwhelming majority of prior-authorization denials patients actually encounter, and each has its own specific, checkable criteria rather than a single generic standard. This guide is organized around that sequence, and every claim in it is stated with the specific qualification the underlying rule actually carries — because in this area, the qualification is usually the part that determines whether a specific situation is covered at all.

What Prior Authorization Means

Prior authorization means a health plan requires advance review before it will treat a specified item or service as covered under the plan's rules. Depending on the plan, it may apply to prescription drugs, imaging, surgery, medical equipment, specialty consultations, rehabilitation, behavioral health services, infusions, genetic testing, facility admissions, and other treatments or services.

Authorization requirements vary among plans and can change. A treatment that did not require authorization under one plan may require it after a change of employer, insurer, benefit package, pharmacy-benefit manager, or calendar year — what was true last year for the same medication is not a reliable guide to what's true this year.

Prior authorization is different from a clinician's treatment recommendation. The treating clinician determines what treatment they recommend; the plan determines whether the request satisfies its coverage terms and utilization-management criteria. Those determinations overlap when the plan evaluates medical necessity, which makes it too absolute to say a denial is never a medical judgment — a denial may rest partly or entirely on a clinical assessment made under the plan's medical-necessity standards. The more precise distinction: a prior-authorization denial is a coverage or benefit determination. It does not, by itself, establish that the treating clinician's recommendation is medically wrong or that the patient does not need the care.

Common Reasons for Denial or Nonapproval

A request may be denied, modified, returned, closed, or held for additional information for many distinct reasons: the submission was incomplete; required records were missing; the diagnosis or code did not match the request; the documentation did not establish a coverage criterion; the plan requires a preferred treatment first (step therapy); a prior treatment trial was not documented; the requested drug is nonformulary; a quantity or frequency exceeds the plan's limit; the provider or facility is out of network; the requested service is excluded from the benefit; the plan considers the service experimental or investigational; the plan determined the request was not medically necessary; authorization was submitted to the wrong entity; or the plan needed clarification.

These are not interchangeable outcomes, and treating them as one thing is the single most common mistake patients make when deciding what to do next. A request for additional information is not necessarily a denial. An administrative closure may not carry the same appeal rights as a formal adverse benefit determination. A partial approval may approve one component while denying another. Before deciding what to do, obtain the exact classification and reason — not a paraphrase of it.

Who Actually Reviews the Request

Prior-authorization processing may involve intake staff, pharmacy or utilization-management staff, automated screening, nurses, pharmacists, physicians, other licensed clinicians, and medical directors. Administrative or automated systems may initially check completeness, eligibility, codes, or whether submitted information matches preset criteria — a request can be rejected before a clinician ever sees it, simply for a coding or completeness mismatch.

Clinical-review requirements differ by program. For Medicaid managed care, a denial or an authorization for less care than requested must be made by a person with appropriate expertise in the patient's relevant medical, behavioral-health, or long-term-care needs. For Medicare Advantage reconsiderations involving medical necessity, the reconsidered determination must be made by a physician with expertise appropriate to the services at issue — though that reviewing physician does not always have to share the treating physician's exact specialty or subspecialty. Other commercial plans are governed by their own plan documents and applicable federal or state requirements, which vary.

The reviewer ordinarily works from the submitted record alone. Missing documentation can therefore affect the outcome even when the treating clinician believes the medical need is obvious — the reviewer cannot act on what wasn't sent.

Federal Deadlines Beginning in 2026

The 2024 CMS Interoperability and Prior Authorization Final Rule, CMS-0057-F, established operational requirements for specified payers. For non-drug medical items and services, covered payers generally must send a decision within 72 hours for an expedited request and seven calendar days for a standard request. The affected payer categories include Medicare Advantage organizations, state Medicaid fee-for-service programs, state CHIP fee-for-service programs, Medicaid managed-care plans, and CHIP managed-care entities. The deadlines apply as expeditiously as the patient's condition requires — the maximum deadline is not permission to wait when the medical circumstances require a faster response.

Qualified Health Plan issuers on the federally facilitated Exchanges are affected by several other parts of CMS-0057-F — including specific-reason and public-reporting provisions — but they were excluded from the rule's finalized 72-hour and seven-day decision deadlines specifically. In April 2026, CMS proposed extending comparable non-drug deadlines to those QHP issuers beginning in 2027; as of August 5, 2026, that remains a proposed, not final, rule, and should not be described as a current patient right.

CMS-0057-F's principal prior-authorization process provisions concern non-drug items and services. Prescription-drug authorization is governed by other federal, state, Medicare Part D, Medicaid, and plan-specific rules instead. CMS proposed broader federal drug-prior-authorization requirements in 2026, but those proposals should not be described as current final law unless and until a final rule actually issues.

Extensions and Requests for More Information

A request for additional information does not automatically restart every deadline, and the effect depends entirely on the governing program — there is no single, universal “restart the clock” rule despite how often that's assumed. Medicaid managed-care rules, for example, permit an extension of up to 14 calendar days when the enrollee or provider requests the extension, or when the plan can justify its need for additional information and explain why the extension is in the enrollee's interest. The plan must still act as expeditiously as the patient's condition requires even during that extension.

Other programs have different extension provisions entirely. Rather than assuming, ask directly: on what date was the request received? Was it considered complete? What deadline applies? Has the plan invoked an extension, and under which specific rule? What information remains missing? Was the extension notice provided in writing? Do not assume that each new fax or document restarts an entirely new authorization period — confirm it, in writing, every time.

California Deadlines for Medical Services

For plans regulated under California's Knox-Keene Act, medical-necessity decisions concerning prior or concurrent authorization generally must be made within five business days after receipt of the information reasonably necessary and requested by the plan, or within 72 hours (or a shorter applicable federal period) when the patient faces an imminent and serious threat to health, or when ordinary processing could seriously jeopardize life, health, or the ability to regain maximum function. Comparable California Insurance Code requirements apply to state-regulated health insurers.

These California timelines do not necessarily govern self-funded employer health plans, Medicare plans where federal requirements control, Medi-Cal arrangements governed by separate rules, or plans regulated outside California entirely. A patient should not assume that the words “PPO,” “HMO,” or “employer plan” alone identify the regulator — the Evidence of Coverage, insurance card, employer benefits administrator, DMHC, or California Department of Insurance can help identify which framework actually controls a specific plan.

California Prescription-Drug Requests

California has separate rules for many prescription-drug prior-authorization and step-therapy exception requests. For many state-regulated health plans, after receipt of a completed request, a nonurgent drug decision generally must be communicated within 72 hours, and a request involving exigent circumstances generally must be decided within 24 hours. Under the applicable statute, failure to provide a timely determination may cause the request to be deemed approved for the prescription's duration, including refills — a genuinely significant consequence for the plan when it happens, and worth knowing about if a deadline has clearly passed. Similar provisions exist for state-regulated disability insurers.

These rules contain their own definitions, exceptions, and limits, and do not necessarily apply identically to Medicare Part D, Medi-Cal, self-funded employer plans, drugs administered under a medical benefit rather than a pharmacy benefit, plans operating their own pharmacies, or arrangements where another entity bears delegated financial risk. Ask the pharmacy or prescriber directly whether the issue involves ordinary prior authorization, step therapy, a formulary exception, a quantity-limit exception, a coverage exclusion, a refill-too-soon rejection, or another point-of-sale issue entirely — the answer changes which rule, and which deadline, actually applies.

Pharmacy Rejection Messages

When a prescription will not process, the pharmacist may be able to see a point-of-sale rejection code or message explaining the immediate reason: prior authorization required; refill too soon; quantity limit exceeded; product not covered; preferred alternative required; pharmacy not in network; prescriber identifier problem; coordination-of-benefits problem; or an eligibility issue. Ask the pharmacist to describe the rejection as specifically as possible rather than accepting a general “not covered.”

Do not assume the prescriber's office has no access to the same information. Electronic prescribing and prior-authorization systems increasingly allow prescribers to obtain formulary and rejection information directly, although access remains inconsistent between systems and practices. A useful message to the prescriber: “The pharmacy reports that the claim rejected because [exact reason]. Please confirm whether the office needs to submit prior authorization, a step-therapy exception, a formulary exception, or a corrected prescription.”

Emergency or Bridge Medication Supplies

Do not assume every plan or pharmacy offers a bridge supply — whether one is available depends on the medication, whether it is a controlled substance, the prescription's status, state pharmacy law, plan transition rules, pharmacist judgment, prescriber availability, and patient-safety considerations.

California law permits a pharmacist, in limited circumstances, to refill a prescription without prior prescriber authorization when the prescriber is unavailable, interruption of ongoing care may significantly harm the patient's well-being, and the pharmacist determines that a refill is appropriate. The pharmacist must notify the patient and inform the prescriber within a reasonable time. This authority does not override every federal or state restriction, particularly restrictions affecting controlled substances — it is a limited, judgment-based authority, not a general guarantee.

Ask rather than assume: can the pharmacist provide a limited emergency refill under applicable law? Does the plan offer a transition fill? Can the prescriber provide a clinically appropriate temporary alternative? Is the medication unsafe to stop abruptly? Does interruption require urgent medical evaluation? Do not ration, split, substitute, or stop medication without appropriate clinical advice — whatever the insurance situation, that decision belongs with a clinician, not with guesswork at the pharmacy counter.

Reading a Denial Notice

Locate four things in every denial notice, in this order.

What was decided: determine whether the plan denied the entire request, approved part of it, authorized a different level or duration, requested additional information, administratively closed the request, or approved an alternative — these are genuinely different outcomes requiring different responses.

The specific reason: “not medically necessary” may be a legal category, but it is not enough, by itself, for a patient or clinician to prepare a useful response. The notice should also explain the applicable plan provision, the criteria or guideline used, the facts considered, and how the request failed to satisfy the criteria. If it doesn't, ask for that specifically.

The appeal deadline: do not assume every plan uses the same deadline. Employer plans governed by ERISA generally must provide at least 180 days for an appeal of an adverse benefit determination, but Medicare, Medicaid, Marketplace, state-regulated, and other plans each have their own procedures. Follow the deadline stated in the notice and plan documents, not a general rule of thumb.

Expedited review: the notice should explain whether urgent or expedited review is available. Urgency ordinarily depends on whether delay could seriously jeopardize life, health, ability to regain maximum function, or — under some California complaint processes — cause severe pain or another serious threat. A patient's statement that a matter is urgent is important, but a clinician or plan may need to document why the governing expedited-review standard is actually met, not merely asserted.

Outside Review: Knowing When It Applies

Determine whether the denial may qualify for independent medical review, federal external review, a Medicaid state fair hearing, Medicare independent review, or another regulator-administered process. Not every coverage exclusion or contractual dispute qualifies for independent medical review — this is one of the most common false assumptions patients make after a denial, and it's worth checking before investing time in the wrong process.

External review commonly applies to qualifying decisions involving medical necessity, appropriateness, level of care, health care setting, effectiveness of a covered benefit, experimental or investigational treatment, or specified emergency-care disputes. It may not apply to a dispute based solely on an express contractual exclusion, eligibility, premium payment, benefit exhaustion, or another issue that doesn't involve a qualifying medical judgment at all.

For many plans regulated by the California Department of Managed Health Care, the member generally must first submit a grievance to the plan. The member may then seek DMHC assistance when the plan denies, changes, or delays care; the member disagrees with the plan's response; the plan has not resolved the grievance within 30 days; or the situation qualifies for urgent intervention. Immediate DMHC assistance may be available for serious threats to health or specified experimental-treatment disputes. DMHC reports that approximately 73 percent of enrollees submitting Independent Medical Review requests receive the requested treatment or service, based on its 2024 annual-report data — a real and encouraging figure, but a California-specific one that should not be generalized to every appeal or every insurance market.

The California Department of Insurance administers a separate Independent Medical Review process for policies under its jurisdiction, generally applying to qualifying disputes involving medical necessity, experimental or investigational treatment, or emergency or urgent medical services. Pure coverage or contractual-interpretation disputes may not qualify for IMR under CDI either, although other complaint or appeal routes may remain available.

Requesting the Coverage Criteria

Ask for the exact benefit provision, the medical-necessity criteria, the clinical guideline, the step-therapy protocol, the formulary rule, the required prior treatments, and the records relied upon. Rights to these materials vary by plan type.

ERISA-governed plans generally must identify the plan provisions supporting a denial. When the decision relies on a rule, guideline, or protocol, the denial must describe it or state that a free copy is available on request, and relevant claim records generally must also be made available without charge during the appeal process. Medicare Advantage plans have separate transparency and appeal requirements of their own. State-regulated plans may be subject to California disclosure, grievance, and independent-review rules on top of that.

A useful request: “Please provide the specific plan provision, medical-necessity criteria, clinical guideline, formulary provision, step-therapy requirement, or utilization-review protocol relied upon in making this decision, together with the records considered.”

Resubmission, Reconsideration, and Peer-to-Peer Discussion

Before filing a formal appeal, determine whether the matter can be corrected without changing the substantive request. A corrected submission may be appropriate when a report was omitted, prior treatment history was not included, the wrong code was used, a required form was incomplete, a contraindication was not documented, or the plan simply misunderstood the requested service.

A peer-to-peer discussion may be available when the treating clinician needs to explain the clinical reasoning directly to a plan reviewer. Important cautions apply, though, and this is where patients and even clinicians most often lose ground they didn't need to: not every plan offers peer-to-peer review; the opportunity may have a short deadline; it may occur before or after a formal denial; it may not itself be a formal appeal; it may not preserve appeal rights; and it may not toll the appeal deadline. A resubmission also may not stop the appeal clock.

Continue to calendar the formal appeal deadline unless the plan confirms otherwise in writing — not verbally, not by implication. Ask directly: is this being treated as a corrected request, reconsideration, or appeal? Does it preserve my appeal rights? Does it extend any deadline? Is peer-to-peer review still available, who must request it, and by what date?

Building an Internal Appeal

An internal appeal asks the plan to reconsider its decision, and it should address the stated basis of denial directly rather than restating the original request. A useful appeal package generally includes the denial notice; the authorization reference number; the requested treatment; the applicable coverage criterion; evidence showing that the criterion is actually met; dates and outcomes of prior treatments; contraindications to required alternatives; relevant test results; a clinician's explanation of medical necessity; the clinical consequences of delay; supporting guidelines or literature when relevant; and a request for expedited review when the governing standard is met.

Do not rely only on general statements that the treatment is important — a focused appeal directly responding to the plan's stated reason is easier for a reviewer to evaluate, and easier to evaluate favorably, than a broad restatement of clinical urgency without documentation tied to the specific denial reason given.

Appeal Timing Differs by Plan

Medicare Advantage has a multi-level appeal process, and standard and expedited reconsideration timelines differ according to whether the request concerns an item or service, a payment, or a Part B drug. For requests concerning items or services, a standard reconsideration generally must be resolved within 30 calendar days, and an approved expedited reconsideration generally must be resolved within 72 hours. A medical-necessity reconsideration must be performed by a physician with appropriate expertise.

A standard Medicaid managed-care appeal generally must be resolved within a state-established period no longer than 30 calendar days, with an expedited appeal generally resolved within 72 hours; limited extensions are permitted under defined conditions. If the plan fails to comply with applicable timing and notice requirements, the enrollee may be treated as having exhausted the plan appeal and may proceed directly to a state fair hearing.

For many ERISA-governed employer plans, the plan documents and federal claims-procedure rules control, and the denial notice should explain how to appeal, the filing deadline, where to submit the appeal, and the relevant review procedures. For commercial individual and group coverage, federal Affordable Care Act rules, state law, the plan's grandfathered status, and whether the plan is insured or self-funded may all affect the process — consult the denial notice and plan documents directly rather than relying on a universal deadline, because there isn't one.

Authorization and Payment Are Not the Same Thing

Prior authorization is not necessarily a final guarantee that a later claim will be paid. Payment may still depend on eligibility on the date of service; whether the benefit remains active; network status; the authorized provider and facility; the authorized code; the number of visits or units; the authorization's expiration date; claim submission; coding; coordination of benefits; and other plan terms.

But the opposite statement is equally wrong: care delivered without required authorization does not automatically mean the patient owes the entire bill. Responsibility may depend on whether the patient was told authorization was missing; whether the provider was contractually responsible for obtaining it; whether the provider is in network; whether the patient signed a valid financial-responsibility notice; whether the situation was an emergency; and the plan's own member-protection provisions.

When an authorization-related bill arrives: request the authorization record; request the claim and denial codes; ask whether the provider was responsible for obtaining authorization; ask whether the provider may bill the patient under its network contract; ask whether a corrected claim or retrospective review is possible; file a plan grievance when appropriate; and contact DMHC, CDI, Medicare, Medicaid, EBSA, or another applicable agency if the dispute remains unresolved. Do not automatically pay or automatically refuse the bill without first obtaining the governing documents — either extreme response, taken before you know the actual terms, can cost you leverage you'd otherwise have.

Continuity of Treatment

Do not assume every ongoing treatment receives special protection under every health plan — continuity protections are program-specific, not universal. Medicare Advantage rules include important, specific protections: an approved prior authorization for a course of treatment must remain valid for as long as medically reasonable and necessary under the applicable criteria, patient history, and treating-provider recommendation, and a patient switching to a new Medicare Advantage plan while undergoing treatment generally receives at least a 90-day transition period during which the new plan may not require prior authorization for that active course of treatment.

Other plans may have their own transition-of-care, continuity-of-care, formulary-transition, or renewal rules, but the details genuinely vary and shouldn't be assumed to mirror the Medicare Advantage rule. When an established treatment is interrupted, tell the plan and clinician when treatment began, whether it was previously authorized, when authorization expired, what interruption has occurred, what clinical harm may result, and which continuity or transition provision may apply to your specific plan.

Urgent Medical Situations

Insurance escalation is not a substitute for clinical evaluation, ever. Contact the treating clinician promptly when symptoms are worsening, treatment has been interrupted, pain is severe, medication withdrawal is possible, or delay could impair health or function — and seek urgent or emergency care when medically appropriate, regardless of where the authorization stands.

Do not wait for prior authorization when emergency care is needed. Federal and state protections generally prohibit prior authorization requirements for emergency services, although later billing or coverage disputes can still occur separately from the immediate care decision.

For an expedited request or appeal, ask the clinician to document specifically why waiting under the standard timeline could seriously jeopardize life, health, maximum function, or another standard defined by the applicable plan or law. Avoid merely labeling a request “urgent” without the supporting clinical reason attached — the label alone rarely moves a reviewer; the documented reason does.

Helping Another Person

A plan generally will not disclose protected information or discuss another adult's claim solely because the caller is a spouse, parent of an adult, adult child, sibling, or caregiver. The patient may need to complete an authorized-representative form, a HIPAA authorization, a plan-specific permission form, a power of attorney, or another legally sufficient document — and the physician's office may require separate authorization from the health plan even after the plan itself has one on file.

Keep the representative documentation, the authorization reference number, copies of notices, appeal deadlines, call notes, and submission confirmations together in one place. Setting this up before a crisis, rather than during one, saves real time when it matters most.

What to Record

Maintain one log for each request, including patient name and plan identification; requested item or service; ordering clinician; date submitted; method submitted; reference number; standard or expedited status; decision deadline; requests for additional information; dates information was sent; decision date; exact denial language; appeal deadline; resubmission date; peer-to-peer deadline; appeal date; regulator contacts; authorization number; effective dates; approved quantity or visits; and the clinical effects of delay.

Do not record only frustration. Record checkable events — dates, reference numbers, and exact language — because that is what a plan, a regulator, or an appeal reviewer can actually act on, and a frustrated summary without those specifics is much harder for anyone to use on your behalf.

A Worked Example: The Step-Therapy Denial

It helps to walk through one specific denial end to end, because the abstract categories above land differently once attached to an actual sequence of events.

Say a plan denies a biologic medication, citing its step-therapy policy: the plan requires documented failure of two lower-cost alternatives before it will cover the requested drug. The first question is not whether the denial is fair — it's whether the record actually shows what the plan says it doesn't. If the patient tried both required alternatives and that trial simply wasn't documented in the submission, this is a corrected-submission problem, not an appeal problem: gather the visit notes, pharmacy fill records, or a clinician's summary establishing the prior trials, and resubmit specifically addressing that gap, in writing, while separately calendaring the formal appeal deadline in case the resubmission doesn't resolve it in time.

If the patient has a documented contraindication to one of the required step-therapy drugs — a prior adverse reaction, an interacting condition — that is a different kind of response: the step-therapy protocol itself should have (and likely does have) a contraindication exception, and the appeal or resubmission should cite that exception specifically rather than arguing generally that step therapy is unfair. Ask directly whether the plan's step-therapy policy has a documented medical-exception pathway, and if so, what it requires.

If neither alternative was ever tried, and there's no contraindication, the honest position is that the step-therapy criterion genuinely was not met on the current record — in which case the realistic paths are either to actually complete the required trial under the treating clinician's supervision (if clinically appropriate) or to build a medical-necessity argument for skipping the requirement, supported by literature or a peer-to-peer conversation, rather than an appeal that simply repeats the original request without addressing the stated basis for denial at all.

Notice what determines the right response in each version of this example: not the emotional weight of the situation, but the specific, checkable fact pattern against the plan's specific, stated criterion. That is the same discipline worth applying to every denial this guide describes, regardless of the medication or service involved. The pattern generalizes well beyond step therapy specifically — a quantity-limit denial, a network-status denial, and an experimental-treatment denial each have their own version of this same worked example, and each rewards the same habit: read the stated criterion first, establish exactly which fact it turns on, and address that fact directly rather than the general sense of unfairness the denial produces.

What Prior Authorization Does Not Decide

It's worth closing with what this entire process does not resolve, because patients frequently expect a prior-authorization outcome to answer a broader question than it actually does.

A prior-authorization approval does not establish that the treatment was the only reasonable option, that a different treatment would have been wrong, or that the plan agrees with every aspect of the treating clinician's reasoning — it establishes only that the specific request, as submitted, met the plan's specific coverage criteria at that specific time. A prior-authorization denial, symmetrically, does not establish that the treatment was medically inappropriate, that the treating clinician was wrong, or that no coverage route exists — it establishes only that the request, as submitted, did not meet the plan's stated criteria, which is a narrower and more specific finding than 'you don't need this.'

Neither an approval nor a denial resolves questions of malpractice, standard of care, or clinical appropriateness in any broader sense — those are separate legal and clinical questions governed by entirely different standards and, when they arise, different processes. A patient or clinician frustrated by a denial is often frustrated by the right thing, but the frustration is usefully directed at the coverage decision specifically — through the appeal and review paths this guide describes — rather than treated as evidence about the underlying clinical question, which the insurance process was never actually designed to answer. None of this is a reason to accept a denial passively — it is a reason to direct the response at the actual, narrow question the plan decided, using the appeal and review paths this guide describes, rather than at a broader clinical or fairness argument the process was never built to answer. An appeal built around “this was medically necessary and the plan should have known better” tends to be weaker than an appeal built around “the plan’s own stated criterion is X, and the record shows X was actually met,” even when both concern the exact same underlying clinical situation.

What Is Changing

CMS-0057-F requires specified payers to use shorter prior-authorization decision periods beginning in 2026, provide specific reasons for denials, publicly report prior-authorization metrics, and implement electronic prior-authorization APIs primarily beginning in 2027. The API requirements generally concern non-drug items and services.

CMS issued a proposed rule in April 2026 that would expand electronic and timing requirements for drugs and add non-drug decision deadlines for federally facilitated Marketplace QHPs. As of August 5, 2026, that rule remained proposed. Do not describe proposed requirements as existing patient rights until they are finalized and effective — a proposed rule can change substantially, or not be finalized at all, between now and any eventual effective date.

Practical Order of Action

Identify the health plan and the regulator that actually governs it.

Determine whether the request concerns a drug or a medical item or service — the rules differ.

Obtain the submission date and reference number.

Determine whether it is standard or expedited, and confirm which deadline applies.

Obtain the exact decision or missing-information request in writing.

Request the criteria and plan provisions relied upon.

Correct an incomplete submission when that's genuinely the issue.

Preserve the formal appeal deadline regardless of any resubmission or peer-to-peer discussion in progress.

Determine whether peer-to-peer review is available, and get its deadline in writing.

Submit a focused appeal addressing the plan's actual stated reason.

Request expedited handling when the clinical standard for it is genuinely met.

Seek external review only once you've confirmed the dispute actually qualifies for it.

Escalate to the appropriate regulator (DMHC, CDI, CMS, EBSA, or your state Medicaid agency) if internal routes stall.

Keep communicating with the treating clinician about safe alternatives and the consequences of delay throughout.

Seek urgent or emergency care when clinically necessary, regardless of authorization status.

Sample Scripts

Checking status: “I am calling about the prior-authorization request for [item or service], submitted on [date]. Please confirm the date received, the reference number, whether it was considered complete, the applicable decision deadline, and whether anything remains outstanding.”

Requesting the criteria: “Please provide the specific benefit provision, medical-necessity criterion, clinical guideline, step-therapy protocol, formulary rule, or other standard used to evaluate this request, together with an explanation of how the submitted information did not satisfy it.”

Preserving appeal rights during resubmission: “We are providing the additional information requested. Please confirm whether this is being processed as a corrected request, reconsideration, or formal appeal, and whether any existing appeal deadline remains in effect.”

Requesting expedited review: “The treating clinician believes that use of the standard timeframe could seriously jeopardize the patient's [life, health, ability to regain maximum function, or other applicable criterion] because [specific clinical reason]. Expedited review is requested. Please confirm receipt and the applicable deadline.”

Requesting an appeal: “I am appealing the denial dated [date], reference number [number]. The stated reason is [quote reason]. The attached records address that reason by showing [brief explanation]. Please confirm receipt, the appeal deadline, the decision deadline, and whether external review may be available if the denial is upheld.”

Each of these scripts does the same underlying work: it names the specific request, cites the specific reference number and date, and asks a specific, answerable question rather than making a general complaint. A plan representative or clinic staff member can act on a specific question far more readily than on a general expression of frustration, however justified that frustration is — and a written record of the specific question asked is itself useful later, whether or not the answer received was satisfactory the first time it was asked.

General educational information—not legal or medical advice

This guide provides general educational information. It is not medical advice, legal advice, or a determination that a particular health plan violated federal or California law. Prior-authorization rights depend on the plan, benefit, regulator, request type, urgency, and facts. Patients should consult their clinician regarding medical care and review the plan's Evidence of Coverage, denial notice, appeal instructions, and applicable regulator guidance before relying on any specific deadline or right described here.

Questions Worth Asking

Was the request submitted, on what date, and through which channel — and was it marked expedited?

What exactly was denied, and which specific plan provision or criterion was applied?

What is the appeal deadline, and does anything currently in progress (resubmission, peer-to-peer) affect it?

Is expedited review available, and what clinical documentation does it require?

Does this dispute actually qualify for external review, or is it a contractual-exclusion issue that doesn't?

If I proceed without authorization or get billed unexpectedly, who was responsible for obtaining it, and under what network terms?

Takeaway

Prior authorization is a benefit and coverage determination, not a verdict on whether your clinician's recommendation is medically right — and the rules governing how fast it must be decided, what happens when information is requested, and what review options exist afterward differ by plan type, regulator, and whether a drug or a medical service is involved. Federal deadlines beginning in 2026 (72 hours expedited, seven days standard) reach specified non-drug requests at specified payers, not marketplace QHPs and not prescription drugs. California adds its own five-day/72-hour medical-service deadlines and 72-hour/24-hour drug deadlines for state-regulated plans specifically. None of this replaces clinical judgment: preserve every deadline in writing, get the specific denial reason, and treat a genuine medical emergency as a medical emergency regardless of where the paperwork stands. None of the specific deadlines above override that basic structure, and none of them are a substitute for reading your own plan documents and denial notices carefully — the categories in this guide tell you what questions to ask and what a plan is legally required to answer, not what the answer will be in your specific case.

Sources and Authorities

The sources below are provided so readers can confirm the governing text and current agency guidance. Laws, regulations, agency pages, and implementation dates can change; time-sensitive requirements should be checked against the current official source.

CMS — Interoperability and Prior Authorization Final Rule CMS-0057-F — cms.gov

CMS — Interoperability Policies and Regulations — cms.gov

ASTP/ONC — Information Blocking — healthit.gov

45 C.F.R. Part 171 — ecfr.gov

HHS OCR — Right of Access — hhs.gov

www.cms.gov — cms.gov

www.ecfr.gov — ecfr.gov