Prior authorization denied: what to do

Preauthorization and precertification

Prior authorization, also called preauthorization or precertification, is an insurer's decision that a service, drug or equipment is medically necessary. Plans can require it before certain care, except in an emergency.

Two things to know

If you get care that needed approval and did not have it, the plan may deny or refuse to pay.
Approval is not a promise to pay. HealthCare.gov notes that preauthorization does not guarantee the plan will cover the cost.

If your request was denied

Read the reason. It may be missing information, a different treatment was required first, or the insurer says it is not necessary.
Call your doctor's office. Offices often handle these requests and can resubmit with more detail or ask whether a doctor-to-doctor review is possible.
File an appeal. You generally have 180 days from the notice under HealthCare.gov rules. Include a letter from your doctor and your records.
Say if it is urgent. If delay could seriously harm your health, ask for an expedited appeal. In urgent cases you may be able to ask for an external review at the same time.

Keep a record

Write down every call, with the date, time, name and what was said. Keep the denial letter and any reference numbers.

See how to appeal a health insurance denial for the full process.

Want help writing your letter?
Upload your denial letter, explanation of benefits or bill to MyMedReply. It writes your appeal or dispute and cites the rules that usually apply. The draft is free; you pay only to copy it.
Write my appeal

Sources

This guide is general information, not medical, legal or insurance advice. Rules and deadlines vary by plan and state, so your denial letter and plan documents control. Medicare and Medicaid have their own appeal rules.