Quick Answer
Prior authorization (PA) is your insurer's pre-approval requirement for a service. To appeal a PA denial: file within 30 days for urgent care or 180 days for standard care, request a step-therapy override if you have documented prior-medication failures or contraindications, and cite CMS's 2026 PA reform rule plus any state PA law (e.g., 72-hour decision deadlines in 15+ states). AppealArmor drafts a prior-authorization appeal letter from your denial, free, and lists who to copy.
Last updated: 2026-05-25 · Source: AppealArmor · About the authors
Prior Authorization Help
Prior authorization denials delay critical treatment. New CMS rules and state PA reform laws give you stronger rights than ever to fight back — and well-documented appeals tend to be much more successful than the rushed ones most patients send.
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Got a denial letter? Upload a PDF or a photo of it, check the details we read from it, and we’ll draft your appeal.
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Prior authorization (also called "pre-authorization" or "pre-cert") is a requirement by your health insurer that your doctor get approval before performing certain treatments, procedures, or prescribing certain medications. It was originally designed as a cost-control mechanism, but it has become one of the biggest barriers to timely medical care in the United States.
Common reasons for PA denials include: the insurer claims the treatment is not medically necessary, your condition does not meet their step therapy requirements (requiring you to try cheaper options first), the insurer wants additional clinical documentation, the request was submitted incorrectly or with missing information, or your specific plan excludes the service.
According to a 2022 American Medical Association survey, 94% of physicians report that prior authorization causes delays in care, 33% report PA has led to a serious adverse event for a patient, and 24% report PA has led to a patient's hospitalization.
Sources: AMA Prior Authorization Physician Survey 2022, CMS data, state insurance department reports
Upload the prior authorization denial notice. AppealArmor reads the denial reason, the service and the appeal deadline, and you confirm every detail before anything is written. No forms to fill out.
AppealArmor answers the reason on your denial and quotes the federal appeal rules for your type of plan. It does not research state prior-authorization laws or CMS coverage determinations for you.
Your packet is the appeal letter (Word and PDF) and a Next Steps sheet: where to send it, your deadline as your letter states it, who to copy, and who to contact if it is denied again. If your case is urgent, ask your insurer for an expedited (72-hour) appeal as well.
Requires Medicare Advantage and Medicaid managed care plans to respond to standard PA requests within 7 days and urgent requests within 72 hours. Plans must provide specific denial reasons and cite the clinical criteria used. Applies to MA, Medicaid MCO, CHIP, and Marketplace plans.
Over 30 states have enacted prior authorization reform laws since 2020. Common provisions include gold-carding (exempting high-approval physicians from PA), continuity of care protections during plan changes, real-time PA decision requirements, and penalties for delayed PA responses. Your state insurance regulator can tell you which state laws apply to your situation.
The Affordable Care Act guarantees your right to appeal any PA denial through internal review and, if unsuccessful, through external independent review. Expedited appeals must be available for urgent situations where delay could cause serious harm.
Yes. Every health plan is legally required to offer an appeal process for PA denials. Under the ACA, you have the right to internal appeal and external independent review. The CMS Final Rule adds new requirements for Medicare Advantage and Medicaid plans. You typically have 180 days to file, though you should act quickly to avoid treatment delays.
Most commercial plans give you 180 days from the denial date. ERISA plans require at least 180 days. Medicare Advantage allows 60 days for standard reconsiderations. For urgent situations, request an expedited appeal immediately -- insurers must decide within 72 hours (24 hours for MA urgent cases). Check your denial letter for the specific deadline.
You can still appeal for retroactive authorization. This is especially strong if the service was an emergency (which cannot legally require PA), if the PA requirement was not clearly communicated, or if the service was medically necessary and would have been approved. Emergency services are protected under the ACA and the No Surprises Act regardless of PA status.
Finalized in January 2024, CMS-0057-F requires faster PA decisions (7 days standard, 72 hours urgent), specific denial reasons with clinical criteria, and public reporting of PA metrics. It applies to Medicare Advantage, Medicaid managed care, CHIP, and Marketplace plans. Many states have passed their own reforms with even stronger protections for commercial insurance.
Request an expedited appeal if delay could harm your health. Have your physician certify medical urgency. File a simultaneous complaint with your state insurance commissioner. Ask your doctor to request a peer-to-peer review with the insurer's medical director -- this often resolves denials within 24-48 hours without a formal appeal.
Upload your prior authorization denial, check every detail we read from it, and get an appeal letter plus a Next Steps sheet. Free, fast, and built to win.
Generate Your Prior Auth Appeal Now — FreeFree, always. No account. You review every word before you send it — and we never send anything to your insurer. You do.
Upload your denial letter — a PDF or a photo of the paper letter works. You check every detail we read from it, then we draft the appeal and quote the federal appeal rules for your type of plan. You read it, change anything you want, and send it yourself.
Start my free appeal →Free, always. No account. You review every word before you send it — and we never send anything to your insurer. You do.
