Here's the short version. Prior authorization means your Medicare Advantage plan must approve certain care before it will pay. Federal rules now require plans to answer within 72 hours for urgent requests and 7 calendar days for standard ones. Plans must also give a specific reason for any denial. If your plan says no, you have the right to appeal. You or your doctor can file within 65 days of the denial notice. If the plan says no again, your case goes to an independent reviewer automatically. Don't take a denial as the final word.
What Prior Authorization Is
In a Medicare Advantage plan, coverage decisions are called organization determinations. You have the right to ask your plan, orally or in writing, whether a service, drug, or supply is covered — before you get it. For certain treatments, tests, and procedures, the plan requires this approval in advance: that's prior authorization. Your doctor usually submits the request and the medical records that support it.
This is one of the big practical differences from Original Medicare, which generally doesn't require prior authorization. Our Medicare Advantage guide covers the trade-offs.
One protection worth knowing: sometimes a plan provider refers you for a covered service, or to a provider outside the network, without getting the plan's approval first. That's called "plan directed care." In most cases you won't have to pay more than the plan's usual cost sharing. Check with your plan about this protection.
The New Decision Deadlines (Since January 2026)
A federal rule (CMS-0057-F) tightened prior authorization for Medicare Advantage plans, state Medicaid and CHIP programs, Medicaid and CHIP managed care plans, and Marketplace plans on the federal exchange. Starting with compliance dates that generally began January 1, 2026:
- Plans must send prior authorization decisions within 72 hours for expedited (urgent) requests and 7 calendar days for standard requests. (This timeframe rule doesn't apply to Marketplace plans, and none of these policies apply to prior authorization for drugs.)
- Denials must include a specific reason, whatever method the plan uses to respond — portal, fax, email, mail, or phone. That makes it easier for your doctor to fix and resubmit the request.
- Plans must publicly report prior authorization metrics on their websites every year, starting by March 31, 2026.
Before You Get Care: Ask First
- Check whether approval is needed. Your plan's "evidence of coverage" booklet lists which services need prior authorization. Member services can tell you too.
- Ask your plan for an organization determination if there's any doubt. You have the right to one, orally or in writing.
- Have your doctor send strong documentation. Requests are judged on medical necessity, so the medical records matter.
- If it's urgent, say so. Ask for an expedited decision when a standard wait could harm your health.
If Your Plan Says No: Appeal
A denial is the start of a process, not the end of it. Ask your provider for any information that could make your appeal stronger before you start.
- Read the denial notice. It must state the specific reason and explain how to appeal.
- File a Level 1 appeal (a "reconsideration") within 65 days of the date on the denial notice. You, your representative, or your doctor can file; for care you haven't gotten yet, your doctor can ask on your behalf. If you miss the deadline, you must give a reason for filing late.
- Include the essentials: your name, address, and Medicare Number; what you're appealing, the dates, and why; proof of representation if someone files for you; and anything that strengthens your case, like a doctor's note.
- Ask for a fast appeal if waiting is dangerous. The plan must decide within 72 hours if it determines — or your doctor tells the plan — that the standard wait could put your life or health at serious risk. Standard pre-service appeals get a decision in 30 days. Payment appeals take 60 days; Part B drug appeals take 7 days. Timelines can be extended by up to 14 days in some cases.
- If the plan still says no, your case moves up automatically. The plan must forward any full or partial denial to an Independent Review Entity (IRE) — an outside reviewer — for a Level 2 appeal. You don't have to request it.
- Keep going if needed. After the IRE, there are three more levels: a hearing with the Office of Medicare Hearings and Appeals, the Medicare Appeals Council, and federal court. Each decision letter tells you how to reach the next level. Our appeals levels and timelines reference maps the whole ladder.
Free help is available. Your State Health Insurance Assistance Program (SHIP) gives free, personal help with appeals. You can also appoint a trusted family member or friend as your representative.
Common Questions
Is it worth appealing a prior authorization denial?
Often, yes. Many denials come down to missing paperwork, and the plan must now tell you the specific reason. Your doctor can fix that and resubmit. Appealing costs nothing, your doctor can file for you, and a second "no" goes to an independent reviewer automatically.
Does Original Medicare use prior authorization?
Generally no — that's a key difference between Original Medicare and Medicare Advantage. See our side-by-side comparison. Neither option is "better" for everyone; they trade flexibility against costs and extras in different ways.
What about my prescription drugs?
Drug coverage runs on separate rules. The new decision-deadline and denial-reason rules described above don't apply to prior authorization for drugs. Drug plans have their own exception and appeal process — see Medicare Part D.
What if my care is being cut off, not denied up front?
You have the right to a fast appeal if you think Medicare-covered services from a hospital, skilled nursing facility, home health agency, rehab facility, or hospice are ending too soon. Your provider must give you a written notice before services end that explains how to ask for one.