How fast must the insurer decide a prior auth appeal?

For many commercial plans subject to federal claims rules, a one-level pre-service appeal is generally decided within 30 days and a qualifying urgent-care appeal within 72 hours. Other plans and programs use different rules, so the denial notice and plan documents control.

Can I get treatment while the appeal is pending?

If care is urgent, request the expedited appeal — 72 hours. For ongoing treatment being cut off, ask about continuation of care protections. Paying out of pocket and seeking reimbursement is possible but risky; ask your provider about self-pay pricing and get any agreement in writing.

Why was my prior authorization denied?

Common causes include unmet clinical criteria, incomplete documentation, coding errors, or a step-therapy or formulary rule. Read the stated reason and review instructions in the denial notice because the response depends on the issue and plan type.

Prior authorization denied: what to do next

UPDATED JULY 12, 2026 · U.S. PLANS · NOT LEGAL OR MEDICAL ADVICE

A prior-auth denial happens before you get care, so timing matters. Many commercial plans subject to federal claims rules use shorter pre-service deadlines, including a 72-hour urgent-care appeal when the applicable medical standard is met. Other plans and public programs can use different rules.

The clocks that matter

Standard pre-service appeal: many one-level commercial-plan appeals subject to federal rules use a deadline of no more than 30 days.
Expedited appeal: many federal rules use 72 hours when the case meets the plan's urgent-care standard; attach the clinician's explanation.
Your filing window: many non-grandfathered commercial and ERISA-covered private employer plans allow at least 180 days; other coverage differs.

First: find out why it was denied

Prior-auth denials hide four very different problems, and the fix depends on which one you have:

Clinical criteria "not met" — really a medical-necessity denial; fight it with a doctor letter answering their criteria.
Step therapy required — see the step-therapy guide; your treatment history may already qualify you for an exception.
Missing information — often the provider's office sent an incomplete request. A quick call to both sides can fix this without a formal appeal.
Administrative/coding errors — wrong code, wrong plan year. Ask the provider's office to resubmit corrected.
Therapy or other behavioral health service — if the prior-auth rule looks stricter than what the plan uses for comparable medical care, federal parity law may apply; see the mental health parity guide.

Call the insurer (member services number on your card) and ask: "What specific criteria were not met, and what documentation would satisfy them?" Log the date, the rep's name, and the reference number.

If care may be urgent, document why

Ask your clinician whether the ordinary review period could seriously jeopardize your life, health, or ability to regain maximum function under the applicable plan standard. If so, put "I am requesting an EXPEDITED APPEAL" in the first line and attach the clinician's explanation. Many plans subject to federal claims rules then use a 72-hour deadline; confirm the exact rule in your notice.

The appeal letter

Free template — prior authorization appeal

[Your name] · Member ID: [ID] Prior Auth Reference #: [number] · [Date] [Insurer] — Appeals Department [Address from denial letter] RE: Appeal of prior authorization denial — [service/procedure/medication], denied [date] [IF URGENT, ADD:] REQUEST FOR EXPEDITED APPEAL To the Appeals Department: I appeal the denial of prior authorization for [service], issued [date]. The stated reason: "[quote the letter]." 1. THE REQUESTED SERVICE MEETS YOUR CRITERIA. Dr. [name] ([specialty]) has determined this service is medically necessary for my diagnosis of [diagnosis]. The enclosed letter of medical necessity addresses your criteria point by point, including [the specific criterion the denial cited]. 2. DELAY HAS CLINICAL CONSEQUENCES. [1–2 sentences: what happens medically if this is delayed or denied. If urgent: "My physician's enclosed statement explains why the standard timeframe would seriously jeopardize my health; I request review under the expedited deadline in my plan and applicable rules."] 3. COMPLETE RECORD PROVIDED. To the extent the original request lacked documentation, the enclosed records complete it: [list]. Please reverse this denial and issue the authorization. If any element remains insufficient, contact me and my provider's office ([provider phone]) before issuing a denial. Enclosed: letter of medical necessity; medical records [list]; copy of the denial letter. Sincerely, [Signature] · [Name] · [Phone]

While you wait

Ask whether a peer-to-peer review is available. It may let your clinician address a medical reviewer directly, but availability and effect are plan-specific. Get written confirmation of whether it changes or pauses the formal appeal deadline.
Get everything in writing; portal messages beat phone calls for the record.
If the denial is upheld and the dispute is eligible, follow the notice's instructions for external review. A pre-service medical-judgment denial may qualify; not every administrative or eligibility denial does.

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Frequently asked questions

Can I get the treatment while appealing?

If the case meets the plan's urgent-care standard, ask for expedited review and attach the clinician's explanation. If ongoing treatment is being cut off, ask which continuation-of-care rules apply. Self-paying and seeking reimbursement afterward is possible but risky; get self-pay pricing in writing and do not assume reimbursement.

What's a peer-to-peer review?

A plan-specific discussion between your clinician and a medical reviewer. It may resolve a clinical mismatch, but it is not universally available and may not replace, extend, or preserve a formal appeal. Ask the plan in writing how it affects your deadline and appeal rights.

The office says they'll "resubmit" — should I still appeal?

Resubmission fixes administrative problems, but it doesn't stop your appeal clock and doesn't create appeal rights. If the denial was clinical, file the appeal in parallel — you can always withdraw it if the resubmission works.