Prior authorization stuck

If your plan has not answered a prior authorization request, the first job is to find out whether it is late. Many requests are “pending” because the plan asked your doctor for more information and the request was never sent. Others are simply overdue. The deadlines below tell you which.

What this means

Prior authorization is the plan’s advance approval for a service, drug or stay. A silent plan is not a yes. For most coverage types, though, the plan has a fixed time to decide and a duty to tell you what it needs.

Employer plans (job-based) and individual or Marketplace plans that are not grandfathered:

• An urgent request must be decided as soon as possible and within 72 hours.
• A non-urgent request must be decided within 15 days. The plan may extend once, by up to 15 days, for matters beyond its control, but it must tell you before the first 15 days end.
• If an urgent request is incomplete, the plan must tell you what is missing within 24 hours. It must give you at least 48 hours to supply it and decide within 48 hours after it receives it.
• If a non-urgent request is incomplete, you must be given at least 45 days to supply the information.
• The clock starts when the request is filed under the plan’s reasonable procedures, whether or not everything needed came with it.

Medicare Advantage: 7 calendar days for items and services subject to prior authorization (since 1 January 2026), extendable by up to 14 days in limited cases, with written notice. 72 hours if your doctor says waiting could seriously harm your health.

Medicaid and the Children’s Health Insurance Program (CHIP): 7 calendar days standard, extendable by up to 14 days, and 72 hours expedited. Medicaid managed care plans may extend an expedited decision by up to 14 days. State law can set a shorter time. The 7-day rule does not cover drugs. For Medicaid managed care plans, the 7-day rule begins with contract years that start on or after 1 January 2026. A Medicaid managed care decision that is not made in time counts as a denial.

The 72-hour and 7-day deadlines in the federal prior authorization rule (CMS-0057-F) do not cover employer plans or Marketplace plans. Their deadlines stay at 72 hours urgent and 15 days standard. Check the date on your notice, which controls, and your state’s rules, which may be shorter.

What to do

1. Pin down the date and method. Ask your doctor’s office when and how the request was sent (portal, fax or phone) and for the reference number. (Your doctor’s office.)
2. Call the plan and ask the status. Ask whether the request is complete, what is missing, and the exact date a decision is due. Write down the name, date, time and reference number. The call log helps. (You.)
3. Send what is missing the same day. If the plan asked for records, ask the office to send them and confirm receipt. (Your doctor’s office.)
4. If delay could harm you, ask your doctor to say so in writing. For employer plans, a physician who knows your condition can make the claim urgent, and the plan must treat it that way. (Your doctor.)
5. Count the days. Use the decision clock to check whether the plan is late.
6. Send a written reminder if the plan is late. Use the missed deadline letter. Send it in a way that gives you proof of the date. (You.)
7. Complain to the regulator if it stays silent. For an insured plan, that is the state insurance department. For a self-funded employer plan, it is the federal Department of Labor. See the guides linked below.

What the plan may say, and what to say back

“We never received the request.” If a request was sent the wrong way but reached the unit that handles benefits and named you, your condition and the treatment, the employer-plan rule requires the plan to tell you the correct procedure within 5 days (24 hours if urgent). Ask for that notice in writing.

“The request is pending clinical review.” Ask for the date the review began and the date a decision is due. For Medicare Advantage and Medicaid, ask whether the plan has taken a written extension and why.

The rule

A plan must decide a pre-service claim within 15 days (urgent: 72 hours), and the clock runs from filing even when information is missing. 29 Code of Federal Regulations (CFR) 2560.503-1

Watch for

• A late answer is not an approval. The federal rules this site relies on do not say a late answer counts as an approval for employer or Marketplace plans. For employer plans, a plan that fails to follow the claims rules is treated as having let you finish its internal process, so you may go to external review or court. In Medicare Advantage, failing to act in time is itself something you can appeal. Talk to the regulator or a legal aid group before suing.
• State rules can be faster. Some states set shorter prior authorization deadlines for insured plans, and a few treat a late answer as an approval. See your state page, such as Vermont or Delaware. Delaware’s approval rule covers drugs now and other services for policies issued or renewed after 31 December 2026. Alaska’s 72-hour rule applies only to plans issued or renewed on or after 1 January 2027, and Washington sets shorter deadlines. Self-funded employer plans are outside state insurance law.
• Do not delay urgent care waiting for paperwork if your doctor says care cannot wait. Ask the provider and the plan about options, and ask for an urgent decision.

What next

• Prior authorization denied: when the answer comes back no.
• Get a fast decision: how urgent appeals work.
• Keep a call log: the record that proves the dates.
• Complain to your state insurance department: how a complaint works.