What Is Prior Authorization, and How Do You Get It Approved Faster?

On this page

• What prior authorization is
• How long it takes
• How to get approved faster
• Why so many denials get reversed
• Changes on the way
• Frequently asked questions

What prior authorization is

Your plan uses prior authorization to decide whether a service is medically necessary and covered before you get it. It’s common for:

• MRIs, CT scans and other advanced imaging (see will health insurance pay for an MRI)
• Planned surgeries and hospital stays (see what type of health insurance covers surgery)
• Specialty and brand-name drugs, often with step therapy, where you have to try a cheaper drug first
• Medical equipment like wheelchairs and CPAP machines
• Physical therapy, home health care and rehab stays

It’s different from a referral. A referral is when your primary care doctor sends you to a specialist, which many HMOs require. Prior authorization is approval from the insurance company itself. For how referrals work in different plans, see what is an EPO plan.

If you get care without a required approval, the plan can refuse to pay. Depending on your plan and your provider’s contract, you could end up with the bill. Always ask before a scheduled test or procedure whether approval is needed and whether it has been granted.

How long it takes

Type of plan	Urgent request	Standard request
Medicare Advantage, Medicaid and CHIP	72 hours	7 calendar days
Employer and individual plans	72 hours	15 days, with one possible 15-day extension

Urgent means that waiting the standard time could seriously harm your life, health or ability to regain function. Your doctor can ask for an urgent review.

Plans covered by the 2026 federal rule also have to give a specific reason when they deny a request and post their approval and denial statistics online each year.

How to get approved faster

1. Ask early. As soon as your doctor recommends a test, surgery or new drug, ask whether your plan requires prior authorization. Your plan’s website or member services line can tell you.
2. Make sure the request is complete. Incomplete requests are a common reason for delays. Ask the office to include your diagnosis, relevant notes and test results, and any treatments you’ve already tried.
3. Ask for an urgent review when your health could suffer from waiting. That cuts the deadline to 72 hours.
4. Get a reference number and follow up. Call the plan a few days after the request goes in. Ask what’s missing and when a decision is due.
5. Ask your doctor about a peer-to-peer review. If the plan says no, your doctor can often talk directly with the plan’s medical reviewer, which sometimes resolves it quickly.
6. Appeal a denial. You have the right to an internal appeal and then an independent external review. See how to appeal a health insurance claim denial.
7. Plan ahead when you switch plans. A new plan may not honor your old approvals. Ask your new insurer before your old coverage ends, and have your doctor submit new requests early.

Some states have gold card laws that exempt doctors with high approval rates from prior authorization for certain services. Texas is the best-known example. In practice, few doctors benefit so far: only 5% of physicians said they contract with plans offering such programs in a 2025 American Medical Association survey.

Why so many denials get reversed

KFF found that in 2024, Medicare Advantage insurers denied 4.1 million prior authorization requests. Only 11.5% of those denials were appealed, and 80.7% of appeals ended with the denial overturned. Denial rates varied a lot by insurer, from 4.2% to 12.8%.

Doctors report real harm from the process. In the AMA’s latest survey, 95% of physicians said prior authorization delays care, and 26% said it had led to a serious adverse event for a patient, such as a hospitalization.

The lesson for patients is simple: a denial isn’t the end. If your doctor thinks you need the care, appeal.

Changes on the way

• Faster electronic approvals. Under the CMS rule, Medicare Advantage, Medicaid, CHIP and HealthCare.gov plans have to support electronic prior authorization systems by January 2027. CMS has also proposed extending the faster timelines to prescription drugs, but that rule isn’t final.
• An insurer pledge. In June 2025, major insurers covering most Americans promised to cut the number of services that need prior authorization, honor existing approvals when patients switch plans, and give real-time answers for most requests by 2027. It’s voluntary. In an AMA survey of 1,000 physicians taken in December 2025 and released in May 2026, only a third expected it to make a meaningful difference.
• Original Medicare pilot. Original Medicare rarely requires prior authorization, but a six-year pilot that started in January 2026 adds a review for some services, such as knee arthroscopy and certain nerve stimulator implants, in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington. Your provider either gets prior authorization or the claim is reviewed before it’s paid. See Medicare open enrollment if you’re weighing Medicare Advantage against Original Medicare.

Comparing plans? Ask each insurer which services need prior authorization before you enroll. Get quotes in your area.

Frequently asked questions

How long does prior authorization take?

Urgent requests must be decided within 72 hours. Standard requests take up to 7 days in Medicare Advantage and Medicaid, and up to 15 days in most employer and individual plans.

Who is responsible for getting prior authorization?

Usually your doctor’s office submits it, especially for in-network care. But it’s your coverage, so confirm the approval is in place before a scheduled service.

What happens if prior authorization is denied?

You’ll get a written reason. You can appeal to the plan and, if it still says no, ask for an independent external review.

Does an approval guarantee the plan will pay?

It usually means the plan will cover the service, but a claim can still be denied for other reasons, such as your coverage ending before the service date.

This article is general information, not medical or legal advice. Prior authorization rules differ by plan, so check your plan documents. Last reviewed September 2026.