Prior Authorization: Why It Delays Care and What to Do About It

Your doctor orders a procedure or medication. Then, before anything happens, your insurance company says it needs to review the request first. That review — called prior authorization — is one of the most common reasons care gets delayed or denied.

Here's what the process actually involves, why it takes as long as it does, and what you can do to keep things moving.

What prior authorization is and why it exists

Prior authorization (sometimes called "prior auth," "pre-auth," or "pre-certification") is a requirement that your insurance company approve certain services before you receive them. It applies to specific prescription drugs, surgeries, imaging scans like MRIs, specialist referrals, and some medical devices.

Insurers use the process to review whether a service meets their criteria for medical necessity — their own standard for what's appropriate given your diagnosis and clinical history. A service being standard practice in medicine doesn't automatically mean your specific plan approves it without review.

The practical effect is a waiting period between when your provider requests care and when you can actually get it. According to the American Medical Association's 2024 prior authorization survey, 94% of physicians reported that prior authorization delays access to necessary care, and 89% said it can negatively affect patient outcomes.

How the process works, step by step

Understanding the steps helps you spot where delays are most likely to happen.

1. Your provider submits a request. After determining you need a specific service, your provider's office sends a prior authorization request to your insurer. This usually includes clinical notes, diagnostic codes, and supporting documentation.
2. The insurer reviews the request. A utilization management team — often including nurses and physicians employed by the insurer — reviews the submission against the plan's coverage criteria.
3. The insurer responds. They approve, deny, or ask for more information (called a "peer-to-peer" request, where your doctor speaks directly with the insurer's reviewer). Response times vary, but CMS rules for Medicare Advantage plans currently require urgent requests to be decided within 72 hours and non-urgent requests within 7 calendar days.
4. Care is scheduled (if approved). Once approved, you can move forward with the service.

Commercial and employer-sponsored plans often follow similar timelines, but they aren't subject to the same federal rules. Check your Summary of Benefits and Coverage for your plan's specific commitments.

Why denials and delays happen

Requests get stuck or denied for a few common reasons:

• Missing documentation. If the submission didn't include enough clinical detail, the insurer may pend it while requesting more records.
• Step therapy requirements. Some plans require you to try a lower-cost treatment first before approving a more expensive one — even if your provider has clinical reasons to skip ahead. This is sometimes called a "fail first" policy.
• The service isn't covered under your plan. Prior auth review can surface benefit limits that weren't obvious from the plan summary.
• Administrative backlogs. High volume and manual fax-based submissions still common in the industry slow turnaround on both the provider and insurer sides.
• Coding mismatches. A diagnosis code that doesn't align with the requested service triggers additional review.

Most of these are fixable, but fixing them requires knowing where the holdup is.

What you can do to move things forward

You have more leverage in this process than it might feel like.

Ask your provider's office for the authorization number and status. Once a request is submitted, it gets a tracking number. Call the office to confirm the request was actually submitted and get that number. Then you can call your insurer's member services line to check status directly.

Request a peer-to-peer review. If a request is denied or stuck in limbo, your provider can ask to speak directly with the insurer's medical reviewer. Many denials are reversed at this stage. Ask your provider's office whether they've tried this option.

Ask about an expedited review. If your condition is urgent, federal rules for certain plan types require faster turnaround. Ask your insurer explicitly whether your situation qualifies for expedited review.

Check for exceptions and appeals. If a request is denied, you have the right to appeal. Your insurer is required to provide a written explanation for any denial. The Affordable Care Act gives you the right to an internal appeal and, if that fails, an external review by an independent organization. Your insurer's denial letter must include instructions for how to file.

Ask about an emergency supply (for medications). If you're waiting on a drug authorization and have run out, your pharmacist may be able to dispense a limited emergency supply depending on your state's laws and the medication type. Ask the pharmacist directly — not your insurer — about what's possible.

Keep records of everything. Write down the date, time, and name of every person you speak to at your insurance company. These notes matter if you escalate to an appeal or file a complaint.

Federal reforms changing the landscape

Prior authorization rules have been shifting. In 2024, CMS finalized a rule requiring Medicare Advantage, Medicaid managed care, and ACA marketplace plans to implement electronic prior authorization systems by 2027, with the goal of reducing processing times and improving transparency. The rule also requires insurers to provide specific clinical reasons for any denial.

Separately, many states have passed laws limiting step therapy requirements or setting maximum turnaround times for commercial insurers. Rules vary by state, so the specifics depend on where your plan is regulated. Your state insurance commissioner's website is the best place to check what protections apply to you.

These changes are still rolling out, so your experience will depend on the type of plan you have and when your insurer implements the new requirements.

When to involve outside help

If you've exhausted the internal appeal process and the denial stands, you still have options:

• External review. You can request that an independent review organization — not affiliated with your insurer — evaluate the denial. For most plans, this right is guaranteed under the ACA.
• State insurance department complaint. Your state's insurance regulator can investigate whether your insurer followed its own procedures. Find your state's department at the National Association of Insurance Commissioners directory.
• Patient advocate. Some hospitals and health systems employ patient advocates who are familiar with insurer processes and can intervene on your behalf. Ask whether the facility you're working with has this resource.

Where to go from here

If you're waiting on a prior authorization and need to see a specialist, use the ProviderQuoHealth directory to identify in-network providers in your area while the process resolves. For specific specialties — imaging, specialist referrals, or procedures that commonly trigger prior auth — you can search by specialty directly, such as radiology or orthopedic surgery, to compare what's available to you in-network.

Your insurer's member services line and your provider's office are your two main points of contact throughout this process. Both have access to information you don't, and both have a role in moving a stalled request forward.

Important note

This article is for general information and is not medical advice. It is not a substitute for professional care from a licensed clinician. If you have a medical concern, talk to a healthcare provider. If you are experiencing a medical emergency, call 911 (in the U.S.) or your local emergency number.