✔ Backed by: HealthCare.gov · Medicare.gov · Centers for Medicare & Medicaid Services (CMS). Each fact links to its source, and the full list is at the bottom of this post.

Maria’s doctor ordered an MRI for her knee. She took the day off work, set up a ride, and showed up on time. Then the front desk told her, “We can’t do the scan today. Your plan hasn’t given prior authorization yet.” Maria went home with no scan, a lost day, and a lot of questions.

That approval step has a name: prior authorization. It can stall care, and it often surprises people. The good news is that a few simple habits can help. You can spot it early, keep it moving, and know what to do if the answer is no.

What prior authorization means

Prior authorization is a decision by your health plan that a service, treatment plan, prescription drug, or piece of medical equipment is medically necessary. You may also hear it called preauthorization, prior approval, or precertification.[1] Your plan may require it before you get certain services, except in an emergency.[1]

Here is the part many people miss: approval is not a promise that the plan will pay the full cost.[1] You may still owe a copay, coinsurance, or your deductible. Approval just means the plan agreed the care fits its rules.

Usually, your doctor’s office sends the request. But you are the one who feels it when the request is late, missing paperwork, or denied. That is why it helps to know how it works.

Which plans use it

Rules depend on your type of coverage. In Original Medicare, you usually do not need this approval for services or supplies to be covered. In a Medicare Advantage plan, you may need approval from your plan before it covers certain services or supplies.[2] Medicare Advantage plans may also require a referral to see a specialist, while Original Medicare usually does not.[2]

Medicare drug plans have their own rules. A plan may require prior authorization for some drugs. That means your prescriber may need to show the drug is needed and that you meet the plan’s conditions.[3] Two related rules often show up too:

• Step therapy: you may need to try a certain lower-cost drug, like a generic, before the plan covers another one.[3]
• Quantity limits: the plan may limit how much of a drug it covers over a set time, such as a set number of pills per month.[3]

Employer plans, Marketplace plans, and Medicaid plans can use it too. The best place to check is your plan’s member handbook, website, or the phone number on your insurance card.

Spot it early, before the appointment

The easiest problem to fix is the one you catch early. When a doctor orders a scan, surgery, specialty drug, therapy, or equipment, ask a quick question before you leave the office.

You can say: “Does this need prior authorization from my plan? Who in your office sends the request, and when will it go out?”

Write down the name of the person who handles it. Many offices have a referral or authorization coordinator. That person can become your best friend.

A few days later, you can call your plan and ask: “Has a prior authorization request come in for me? What is the status, and is anything missing?” Have your member ID card ready. Keep a simple log with the date, who you talked to, and what they said. If you are calling for a parent or partner, the plan may need their permission on file before it can talk with you.

Tru-Tips: Ask for a reference number at the end of every call. If you need to call back, that number can save you from starting over.

How long it can take

Waiting is hard, especially when you are in pain or worried. A federal rule from the Centers for Medicare & Medicaid Services (CMS) set time frames for certain plans starting in 2026. It covers Medicare Advantage plans, state Medicaid and CHIP programs, and Medicaid and CHIP managed care plans. These plans must send a decision within 72 hours for urgent requests and within 7 calendar days for standard requests.[4] The rule also says these plans must give a specific reason when they deny a request.[4]

Two limits are worth knowing. The rule does not apply to prior authorization for drugs.[4] And the decision time frames do not apply to Marketplace plans sold on the federal exchange, even though some other parts of the rule do.[4] So always ask your own plan what time frame applies to you.

If waiting could seriously harm your health, ask your doctor’s office whether the request can be sent as urgent (sometimes called expedited). You can say: “My symptoms are getting worse. Can you ask the plan for an urgent review?”

If the answer is no

A denial is not always the end of the road. Sometimes the plan simply needed more information. Start by finding out the exact reason. Plans must explain why they denied a claim and tell you how to dispute the decision.[5]

Then talk with your doctor’s office. They may be able to send more records or suggest a different option the plan covers. For Medicare drug plans, you or your prescriber can ask the plan for an exception to a coverage rule. Your prescriber will need to send a statement, such as why another drug would not work as well for you.[3]

You also have the right to appeal. For many plans, you can first ask the plan itself to take a full and fair second look, called an internal appeal. If the plan still says no, you may be able to ask for an external review by an independent third party. That way, the insurance company no longer gets the final say.[5] If your case is urgent, the plan must speed up the process.[5] Appeal steps and deadlines differ by plan type, so read your denial letter closely and ask the plan for the exact deadline.

You can say: “I would like to appeal this decision. What is my deadline, where do I send it, and can this be handled as urgent?”

A simple prior authorization checklist

When a new order comes up, walk through these questions:

• Does this need approval from my plan?
• Who is sending the request, and when?
• Did the plan receive it, and is anything missing?
• When should I expect a decision?
• If approved, what will I still owe?
• If denied, what is the reason and my appeal deadline?

Keep your answers in one notebook or a note on your phone, along with any letters from your plan. If a medicine costs too much even after approval, the SynquUp Medication Copay Finder can help you look for savings programs.

One Tru Step: Find the phone number on the back of your insurance card and save it in your phone as “My health plan.” Next time a new test or medicine comes up, you will be ready to ask about prior authorization.

Let’s talk

Have you ever had care delayed while waiting for an approval? What helped you get it moving? Share your tips in the comments so others can learn from them.

Sources and further reading

1. HealthCare.gov: Preauthorization (glossary)
2. Medicare.gov: Compare Original Medicare and Medicare Advantage
3. Medicare.gov: Drug plan rules
4. CMS: Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheet
5. HealthCare.gov: How to appeal an insurance company decision

Sources checked October 20, 2026. General education; individual care and coverage questions require an appropriate professional.

Related Health Hubs

• Insurance and Medicare
• Healthcare Costs and Financial Assistance
• Medication Management and Safety

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