Medicare Advantage Prior Authorization: How Approvals Work and What to Do After a Denial

Your doctor asks for a scan, a stay, or a course of care. The plan says it must approve the care first. That step is called prior authorization. It can slow care down, and a no can feel like the end of the road. It is not the end. Federal rules set clocks for the plan, and a set appeal path sits above a denial. This guide shows how approvals work, what clocks bind the plan, and what to do step by step after a no. Our Medicare Advantage section holds more guides on how these plans work.

What prior authorization is

A Medicare Advantage plan is run by a private company. The plan can ask for facts before it agrees to pay for some care. It wants proof that the care fits its cover rules.

Your doctor sends most requests. The office sends notes, test results, and the reason for the care. The plan reads that file and makes a coverage decision.

That decision has a formal name. It is called an organization determination. You do not have to wait for a bill to get one. You, your representative, or your provider can ask the plan for a decision before you get a service.

Some care needs no approval at all. Other care will not be paid if you skip the step. Your plan papers list which services need approval. Check that list before you book care that can wait.

The clocks that bind the plan

Speed counts when care is on hold. Federal rules now set hard clocks for these decisions.

Since January 1, 2026, a plan must send a prior authorization decision within 7 calendar days for a standard request. If the request is urgent, the plan must decide within 72 hours.

Those clocks cover items and services. The rule for drugs is apart from this one. Drug requests run on the drug plan rules, not on these clocks.

A denial must state a specific reason. A vague no is not enough. The plan must say why the care did not pass: a rule not met, a fact not shown, or a step not done. Read that reason word by word. Your appeal must answer that exact point.

Plans must also post their prior authorization track record in public each year. Those reports show how many requests they got, how many they denied, and how fast they ruled. They give you a way to judge a plan before you join it.

Our guide on home health under Medicare Advantage prior authorization shows how these approval steps play out for one common service.

How Original Medicare differs

Original Medicare takes a distinct path. For most services, there is no plan office to ask first. The provider gives the care and sends the claim. Medicare rules then decide if the claim is paid.

The cost rule is more plain too. For most Part B care, you pay 20% of the Medicare-approved amount after the deductible, when the provider accepts assignment (Ledger A16).

That does not mean Original Medicare pays for all care. It pays for care its rules cover. The check just comes after the care in most cases, not before it. That is the core split between the two routes.

Step one after a denial: read the notice

The plan must tell you its decision in writing. Keep that notice. It holds three things you need: the reason for the no, the date the notice was sent, and the steps to appeal.

Do not act from a phone call alone. Ask for the written notice if you do not have it. The appeal clock runs from the date on that notice, not from the day you heard the news by phone.

Ask your doctor for the file the plan saw. Notes or test results may be thin or out of date. A strong appeal adds the facts the first file left out.

Step two: ask the plan to look again

The first level of appeal is called a reconsideration. You ask the plan itself to review its own no.

You must file within 65 days from the date on the plan denial notice. If you miss that date, you must give a reason for the late filing. Do not count on a late pass. Mark the date the day the notice lands.

Follow the steps in the notice and your plan papers to file. Your doctor can ask for a reconsideration for you if the appeal is for a service you have not yet had. Your doctor must tell you that they filed it.

The appeal should meet the denial reason head on. If the plan said a test was not shown, send the test. If the plan said a rule was not met, show how your case meets it, or why an exception fits. A letter from your doctor that ties your facts to the rule helps a great deal.

Step three: ask for a fast appeal if the wait can harm you

Some care cannot wait for the standard pace. If you think your health could be badly harmed by the wait, ask the plan for a fast appeal. The formal name is an expedited appeal.

Your doctor can back that ask. A note from your doctor that states the harm a wait can cause holds a lot of weight. Say in plain words what the wait puts at risk: your life, your health, or your chance to regain full function.

If the plan still says no at this level, the path does not end. There are five levels of appeal in all. Each decision letter tells you how to move to the next level. Read each letter and act by the date it sets.

Who pays for what

Our guide on Medicare Advantage special enrollment periods shows the windows in which you can change plans if a plan fit turns poor.

• Your Medicare Advantage plan pays for care it approves, under its own cost rules. Those rules are in your plan papers.
• Original Medicare pays for covered care with no prior approval step for most services. For most Part B care, you pay 20% of the Medicare-approved amount after the deductible (Ledger A16).
• You pay for care you get with no approval, if the plan rules said approval was a must and no appeal wins it back. Read the plan rules before you book.
• Medicaid can help with Medicare costs for people who qualify through their state. It does not change the plan approval steps.
• Private pay covers care you choose to get at your own cost while an appeal runs. Ask for the full price in writing first.

Sample situation

Linda needs a scan her doctor ordered. Her plan asks for prior authorization. Her doctor sends the request with her notes. Six days pass with no word. On the next day, the plan sends a denial. The notice states a specific reason: the file did not show a prior test the plan rule calls for. Linda reads the notice and checks the date on it. She marks the date 65 days out as her last day to file an appeal. Her doctor finds the test result in her chart and sends it with a letter that ties her case to the plan rule. Linda files the reconsideration well inside the 65 days. She keeps a copy of all she sent. She also writes down the date of each call with the plan and the name she was given on that call. She keeps those notes with the denial notice, so the full path of the case sits in one file. She knows that if the plan says no again, the next decision letter will tell her how to move to the next level.

What to check when approval is in play

A denial is a first decision, not a final word. The rules give the plan a clock, give you a written reason, and give you a path to ask again. Use each one, in order, and keep your papers as you go.

• Check your plan papers. Does this service need approval first?
• Ask your doctor who sends the request and what facts go with it.
• Note the date the request went in. Count 7 calendar days for a standard request, or 72 hours for an urgent one.
• If the plan says no, get the written notice. Read the specific reason.
• Mark 65 days from the date on the notice. That is your appeal deadline.
• Ask your doctor for a letter that answers the denial reason point by point.
• If a wait can harm your health, ask for a fast appeal and get your doctor to back it.
• Keep a copy of each form, letter, and notice. Write down each call: date, time, and the name you were given.

Sources

• https://www.medicare.gov/publications/11525-medicare-appeals.pdf