How fast must the insurer decide a prior auth appeal?

Standard pre-service appeals are typically decided within about 30 days. If your physician states that waiting would seriously jeopardize your health, you can demand an expedited appeal decided within 72 hours.

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: the request didn't match the insurer's clinical criteria, documentation was incomplete, coding errors, or a step-therapy/formulary rule applies. The denial letter must state the reason — the fix depends on which one it is.

Prior authorization denied: what to do next

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

A prior-auth denial happens before you get care — which means time pressure is part of the design. The good news: pre-service appeals have the tightest legal clocks for insurers, including a 72-hour expedited track when your health can't wait.

The clocks that matter

Standard pre-service appeal: insurer must decide in ~30 days.
Expedited appeal (urgent): decided within 72 hours — your doctor just has to say waiting endangers you.
Your filing window: at least 180 days from the denial notice.

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.

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 is urgent, say the magic words

Ask your doctor whether waiting 30 days is safe. If not, your appeal's first line should read: "I am requesting an EXPEDITED APPEAL" — with a physician's statement that delay would seriously jeopardize your health. That legally compresses the decision to 72 hours.

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 — 72-HOUR REVIEW REQUESTED 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 confirms that the standard timeframe would seriously jeopardize my health; I therefore request expedited review within 72 hours."] 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 your provider's office to submit a peer-to-peer review — your doctor speaks directly with the insurer's medical director. It frequently resolves prior-auth denials fast.
Get everything in writing; portal messages beat phone calls for the record.
If the denial is upheld, go to external review — pre-service denials qualify too.

Time-critical? Move faster

Upload the denial. The packet's ready in ~15 minutes.

GetMyYes drafts your appeal letter, the doctor letter request, and the insurer call script from your actual denial — and tracks your deadlines so the clock works for you, not against you.

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Frequently asked questions

Can I get the treatment while appealing?

If urgent — use the expedited track (72 hours). If ongoing treatment is being cut off, ask about continuation-of-care rules. Self-paying and seeking reimbursement afterward is possible but risky; get self-pay pricing in writing first.

What's a peer-to-peer review?

A call between your doctor and the insurer's reviewing physician. It can reverse a prior-auth denial in one conversation and doesn't use up your formal appeal rights. Ask your provider's office to request one.

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.