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For anyone with planned care or a new prescription · Licensed in 20 U.S. states

Prior authorization,
explained.

Prior authorization is approval from your health plan that may be required before you get a service or fill a prescription, so that the plan will cover it. You may also see it called preauthorization, prior approval, or precertification. A yes isn't a promise of payment, and emergencies follow different rules. Here's how the process works and what to do after a no.

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How it works

A yes from the plan
before the care.

HealthCare.gov's glossary describes the process this way:

The plan reviews it first.

A plan may want to sign off on certain services, treatment plans, prescription drugs, or medical equipment before you get them. It is deciding whether the item is medically necessary: needed to diagnose or treat a condition, and in line with accepted standards of medicine.

Approval is not payment.

Getting the green light isn't a promise that the plan will cover the cost. The claim is still processed under your plan's terms, and your deductible, copay, or coinsurance still apply.

Emergencies are different.

The glossary notes that preauthorization rules don't apply in an emergency. Federal rules go further: a plan that covers emergency room care generally has to cover emergency services without any prior authorization determination.

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When a request is denied

A denial has to come with a reason.

These points summarize HealthCare.gov, appealing an insurance company decision, HealthCare.gov, internal appeals, and 45 CFR 156.223, read October 31, 2026.

Your insurer has to tell you in writing why it turned down a claim or request, and how you can dispute the decision.
HealthCare.gov lists common reasons: the benefit isn't offered under your plan, the provider isn't in the plan's network, or the plan calls the treatment not medically necessary, or experimental.
Since January 1, 2026, insurers selling plans on a federally facilitated Exchange must give your provider a specific reason when they deny a prior authorization request for an item or service other than a drug.
Those insurers must also post yearly prior authorization data on their websites by March 31: the items and services that need approval, and the share of requests approved, denied, and approved after appeal.

The deadlines

The clock on a
denial and an appeal.

15 days

How long your insurer has to explain in writing why it denied a prior authorization request. For care you already got, it has 30 days; for urgent care, 72 hours.

180 days

How long you have to file an internal appeal, counted from when you get notice that the claim was denied.

4 months

How long you have to request an external review by an independent third party, counted from the insurer's final denial notice.

Deadlines from HealthCare.gov, internal appeals and HealthCare.gov, external review, read October 31, 2026. Plans that are not subject to these federal rules may use different steps, so check your plan documents.

Paul DanielsLicensed health advisor · NPN 20986580

Working with Paul

We check which care
needs approval first.

Daniels Health Advisors is the independent brokerage Paul Daniels founded, licensed in 20 U.S. states. If you know a surgery, an MRI, or a specialty drug is coming, the approval and referral rules can matter as much as the premium. We look for those rules in each plan's documents for the care you expect, and compare Marketplace plans and, where they fit, private PPO options. Some private plans ask health questions, and approval is not guaranteed. Some may not cover care for health problems you had before you enrolled.

If you already have a denial letter, keep it handy. The claim number and the stated reason are the first things to look at.

Approval and referral rules checked for the care you expect
Licensed in 20 U.S. states · Paul Daniels, NPN 20986580 · FL license G065122
You do not pay us for our help. We are paid by the insurance companies when you enroll. Your price for a plan is the same whether you use us or sign up on your own. Commissions can differ by company.

Your first call

Planning around prior authorization in three steps.

Name the care

Planned procedures, scans, and drugs you take now.

We read the rules

Which items need approval or a referral under each plan.

Choose with a clear view

Know the approval steps before you enroll.

Book a 15-minute call

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Before you schedule

Ask before you
book the procedure.

Before a planned surgery, scan, or new specialty drug, ask the doctor's office whether your plan needs approval and whether it has been granted. In many HMOs, you also need a referral from your primary care doctor before you see a specialist, or the plan may not pay. After the call you will have:

Which of your planned services need approval
Whether a referral is needed for a specialist
What the plan decided, and when
Your next step if the answer is no

A checklist for

Handling a prior authorization denial.

Read the denial letter for the reason and your appeal rights, and file it with your Explanation of Benefits forms.
Ask your doctor for a letter or records that answer the stated reason. Then file the internal appeal on the insurer's forms, or write with your name, claim number, and insurance ID number.
Write down the date, time, name, and title of each person you talk to at the plan or the doctor's office.
If your situation is urgent, ask for an expedited appeal. You can request an external review at the same time.

Prior authorization questions

Prior authorization FAQ.

What is prior authorization in health insurance?

It's approval from your health plan that may be required before you get a service or fill a prescription, in order for the plan to cover it. HealthCare.gov notes it is also called preauthorization, prior approval, or precertification.

Does prior authorization mean the plan will pay?

No. Preauthorization isn't a promise that your plan will cover the cost. The claim is still processed under your plan's terms, including your deductible and cost sharing.

How long does a prior authorization decision take?

It depends on the plan and how urgent the request is. If a plan denies a request for a treatment, it has to tell you in writing within 15 days, or within 72 hours in urgent care cases.

Do I need prior authorization for emergency care?

Generally, no. If your plan covers emergency room care, federal rules generally require it to cover emergency services without any prior authorization determination. Check your plan documents for how to notify the plan after an emergency.

What can I do if my prior authorization is denied?

You can file an internal appeal within 180 days of the denial notice. If the insurer still says no, you can ask for an external review by an independent third party, and the insurer is required by law to accept that decision. Your state's Consumer Assistance Program may be able to file an appeal for you.

Do I have to wait for open enrollment?

Not for every plan. A private plan (not from the Marketplace) can often be bought any time of year. Some private plans ask health questions, and approval is not guaranteed. Some may not cover care for health problems you had before you enrolled. Marketplace plans, and other plans that follow ACA rules, work differently. As of October 31, 2026, under current law, open enrollment for 2027 plans on HealthCare.gov runs from November 1, 2026, to January 15, 2027. To start coverage January 1, pick a plan by December 15. States that run their own Marketplace may set different dates, so check with your state's Marketplace. A federal appeal about these rules is pending (City of Columbus v. Kennedy, 4th Cir. No. 26-1938; oral argument was set for October 30, 2026), so confirm the dates before you enroll. Outside open enrollment, you need a special enrollment period, such as one after losing job-based coverage.

Know the approval rules
before you enroll.

Book a 15-minute call to compare how plans handle approvals, or see quotes online.

Book a 15-minute call Get a quote online

By Paul Daniels, licensed insurance agent (NPN 20986580).

Disclaimer

Daniels Health Advisors LLC is an independent brokerage, not a carrier, HealthCare.gov, or CMS. Agent: Paul Daniels, NPN 20986580, Florida license G065122. This page explains prior authorization in general. Which services need approval, and how requests are reviewed, vary by plan, so read the plan documents. The deadlines come from HealthCare.gov and apply to plans that must follow the federal appeal rules. Tax credits, plans, networks, and prices depend on your state, zip code, income, and household. We never guarantee approval, a doctor, or a price. Not medical, legal, or tax advice.

Prior authorization,explained.

A yes from the planbefore the care.