Prior Authorization Denials: What Patients Can Do When Care Is Delayed
When a health plan requires prior authorization, your doctor or other clinician may need approval before you can receive a treatment, service, medication, medical device, or facility-based care. If the plan delays or denies the request, the next steps can feel confusing, especially when you are already managing chronic pain, a disability, a mental health condition, or another serious health need.
This guide explains what the evidence shows and what patients can generally do when prior authorization is delayed or denied. Rules vary by plan, coverage type, and state, so use your denial notice and plan documents as the final source for your deadlines and instructions.
What is prior authorization?
Prior authorization is a health-plan review that happens before certain care is provided. Plans use it to decide whether a requested service meets coverage rules and medical-necessity requirements. It is common for higher-cost or closely managed services, such as inpatient hospital care, skilled nursing facility stays, some rehabilitation services, certain Part B drugs, and some medical equipment.
According to KFF’s analysis of Medicare Advantage data, 99% of Medicare Advantage enrollees were in plans that required prior authorization for at least some services.
Prior authorization is not the same as a final determination that you cannot receive care. A request may be approved, denied, partially approved, or delayed while the plan seeks more information. If it is denied, you may still have appeal rights.
Why delays and denials matter
A prior authorization delay can create more than an administrative problem. It may postpone treatment, rehabilitation, equipment, or other services ordered by a clinician. For someone living with chronic pain or a disability, a delay may interfere with mobility, daily activities, or a planned transition from a hospital to another care setting. For someone seeking mental health care, uncertainty about access can add another burden during an already difficult period.
The available evidence shows that prior authorization decisions and appeal outcomes vary by insurance program, insurer, service, and patient circumstances. The data does not show that every denial is wrong, but it does show that an initial denial is not always the final answer.
For example, KFF’s analysis of 2024 Medicare Advantage data found:
Plans made nearly 52.8 million prior authorization determinations.
About 7.7% were fully or partially denied.
Only 11.5% of denied requests were appealed.
Of the denials that were appealed, 80.7% were fully or partially overturned.
These figures describe Medicare Advantage service determinations and do not predict the outcome of an individual appeal. As KFF notes, an overturned denial may reflect an incorrect initial decision, additional documentation submitted later, or both.
What recent evidence shows
New federal reporting provides a broader view of prior authorization practices. In an August 2026 analysis, KFF examined publicly available 2025 data from large insurers in Medicare Advantage, Medicaid managed care, and the federally facilitated ACA Marketplace.
Among standard, non-urgent requests, the insurers included in the analysis reported:
12% denied in Medicare Advantage.
14% denied in Medicaid managed care.
18% denied in the ACA Marketplace.
After appeal, 67% of Medicare Advantage denials, 47% of Medicaid managed care denials, and 43% of ACA Marketplace denials were approved after appeal.
These percentages should be interpreted carefully. The analysis did not include every plan, and the public reports still leave major gaps. A denial rate for a large insurer may not reflect the rate for your specific plan, state, service, or provider.
Post-acute care has also received particular attention. KFF’s analysis of HHS Office of Inspector General data found that, in June 2024, Medicare Advantage insurers initially denied:
65% of requests for long-term care hospital stays.
54% of requests for inpatient rehabilitation facility stays.
12% of requests for skilled nursing facility stays.
The same analysis reported that these initial denials delayed the requested post-acute care by an average of five to six days. Among appealed denials, the requested service was later approved in 36% of long-term care hospital cases, 43% of inpatient rehabilitation facility cases, and 95% of skilled nursing facility cases. These findings apply to the data reviewed and should not be generalized to every type of care or every plan.
What changed in 2026?
The CMS Interoperability and Prior Authorization Final Rule created new requirements for Medicare Advantage organizations, Medicaid and CHIP fee-for-service programs and managed-care plans, and qualified health plan issuers on the federally facilitated Exchanges.
For affected plans and non-drug medical items and services, the rule requires:
Decisions on expedited requests within 72 hours.
Decisions on standard requests within 7 calendar days.
A specific reason for a prior authorization denial.
Public reporting of certain prior authorization metrics.
CMS says these denial-reason and decision-timing requirements began in 2026, while key API requirements phase in later. For Marketplace plans, HealthCare.gov states that a plan must generally notify you about a prior authorization decision within 15 days, and within 72 hours for urgent-care requests.
The CMS rule’s seven-day and 72-hour prior authorization standards do not apply to prescription drugs. Drug coverage decisions can follow different rules, depending on the program and plan.
If your request is still pending
If your prior authorization has not been decided, consider taking these steps:
Ask whether the request was submitted. Contact the clinician’s office and ask for the submission date, request type, and any confirmation or reference number.
Ask whether it should be expedited. Discuss with your clinician whether waiting through the standard timeframe could seriously jeopardize your life, health, or ability to regain maximum function.
Contact the plan. Ask whether the request is complete, whether additional records are needed, and when the plan received it.
Write down the timeline. Record submission dates, reference numbers, phone calls, names, and promised follow-up dates.
Ask about the next step if the deadline passes. If the plan appears to have missed an applicable deadline, ask how to file a grievance, complaint, or expedited review request under your plan’s rules.
Do not wait for an insurance dispute if you believe you are experiencing a medical emergency. Seek emergency help or call 911 when appropriate.
If your request was denied
1. Get the denial in writing
Read the denial notice carefully. It should explain the reason for the decision and tell you how to appeal. Under the CMS final rule, affected payers must provide a specific reason for denials of covered non-drug items and services.
Keep the complete notice, including the date, claim or authorization number, clinical reason, appeal address, fax number, website, and deadline.
2. Ask your clinician to review the reason
Share the denial with the ordering clinician. Ask whether the request was missing:
Medical records or test results.
Documentation of previous treatment.
A description of your functional limitations.
The requested service’s duration, frequency, or level of care.
Information explaining why another option may not be appropriate.
Your clinician, not an advocate or insurance representative, should provide the medical explanation for why the requested care is appropriate.
3. File the correct type of appeal
Medicare Advantage: A prior authorization denial is generally handled as an organization determination appeal, often called a reconsideration. CMS guidance states that the request generally must be filed within 65 calendar days of the denial notice. A standard pre-service reconsideration is generally decided within 30 calendar days. An expedited request is generally decided within 72 hours. If the plan upholds the denial in whole or in part, the case is generally forwarded automatically to the Medicare Part C Independent Review Entity.
You can also contact 1-800-MEDICARE or a free State Health Insurance Assistance Program counselor through SHIP Help.
Medicaid managed care: Federal Medicaid rules require standard appeals to be resolved within no more than 30 calendar days and expedited appeals within no more than 72 hours, subject to limited extensions in some cases. The current rule is available at 42 C.F.R. § 438.408. Your state may have different filing instructions, forms, or shorter timeframes. If the appeal is denied, the notice should explain your right to request a state fair hearing.
ACA Marketplace plans:HealthCare.gov explains that you generally have up to 180 days to request an internal appeal. For services you have not yet received, a pre-service internal appeal is generally completed within 30 days. If the denial remains in place, you may request an external review, usually within four months of the final denial. Standard external reviews generally must be decided within 45 days, while expedited external reviews generally must be decided within 72 hours.
Marketplace rules can differ depending on whether your plan uses a state or federal review process. Follow the instructions in your denial notice.
A practical appeal checklist
Before submitting an appeal, gather:
Your denial notice.
Insurance member ID and authorization number.
The requested service, treatment, device, or medication.
The clinician’s supporting letter.
Relevant medical records and test results.
A list of treatments already tried and their results.
The deadline and submission instructions.
Proof that the appeal was submitted.
Notes from calls with the plan or provider.
A clear appeal should:
Identify the exact denial being appealed.
Explain why the decision should be reconsidered.
Point to the medical records and plan rules that support coverage.
Address the plan’s stated reason for the denial.
Ask your clinician to respond to the plan’s stated reason rather than sending general information unrelated to the denial.
You may also be able to appoint a representative, such as a trusted family member, caregiver, clinician, or qualified advocate. The plan may require an authorization form.
Conclusion
Prior authorization can be difficult to navigate, but a denial does not always end the process. Current evidence shows that many denied requests are never appealed, while a substantial share of appealed denials are later approved. That does not guarantee approval in any individual case, but it does make it important to read the denial carefully, track deadlines, involve your clinician, and use the appeal rights available through your coverage.
If you are enrolled in Medicare Advantage, Medicaid managed care, or an ACA Marketplace plan, pay close attention to the instructions in your denial notice. The deadlines, forms, and review pathways can differ. When possible, ask your clinician to address the plan’s specific reason for the denial and to explain why the requested care is medically appropriate under your circumstances.
For additional reading, visit the Roy Jones on Wheels blog, including resources about Medicare Advantage and hospital access and chronic pain support groups.
Support-advocacy disclaimer: Roy Jones provides supportive advocacy and motivational assistance. This article is for general educational purposes and is not medical, legal, insurance, or financial advice. We do not guarantee coverage, authorization, appeal approval, or any particular outcome. Contact your health plan, clinician, Medicare, your state Medicaid office, your state insurance department, or a qualified legal or benefits advocate for guidance about your situation.
If you are having difficulty organizing the next steps, Roy Jones may be able to offer supportive advocacy as you identify questions, gather information, and connect with appropriate services.
Sources
Comments