How to Appeal a Prior Authorization Denial
A prior authorization denial means your insurer says the required pre-approval was not obtained before the service was provided. Prior authorization (also called pre-certification or pre-approval) is a process where your insurer reviews a treatment before it happens to decide whether they will cover it.
However, many prior authorization denials are issued incorrectly. The authorization may have been obtained but not properly recorded, the service may not have actually required prior auth under your plan, or the denial may have been issued after an emergency where prior auth was not possible.
62% of prior authorization denials are overturned on appeal.
Your Legal Rights
Under the No Surprises Act and state insurance laws, insurers cannot require prior authorization for emergency services. Many states have also passed prior authorization reform laws that limit when insurers can require it and set time limits for their response. The ACA requires insurers to provide at least 180 days for you to appeal any denial.
How to Appeal: Step by Step
- 1Verify whether prior authorization was actually required for this service under your specific plan.
- 2Check if authorization was obtained but not properly documented (call the provider's office).
- 3If the service was an emergency, cite the No Surprises Act exemption from prior auth requirements.
- 4Obtain documentation from your provider about the authorization attempt or medical urgency.
- 5Write an appeal letter explaining why the prior auth requirement was met or should not apply.
- 6Submit via certified mail within the appeal window.
Common Mistakes to Avoid
- ✕Assuming the denial is valid without checking if auth was actually obtained
- ✕Not citing the emergency exception when it applies
- ✕Missing that your state has stricter prior auth reform laws
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Frequently Asked Questions
What if my doctor's office forgot to get prior auth?
You can still appeal. Many insurers will grant retroactive authorization when the service is medically necessary and properly documented.
Does prior auth apply to emergency room visits?
No. Under the No Surprises Act and most state laws, insurers cannot require prior authorization for emergency services.
Can I just use ChatGPT to write my appeal?
ChatGPT doesn't know whether your state has prior authorization reform laws, can't verify if the No Surprises Act exemption applies, and won't calculate your exact deadline. We handle all of that.