Prior authorization before a procedure: who asks, and who pays if it is missed
Prior authorization is your plan's advance decision that a service is medically necessary. The provider usually requests it, and an employer plan generally has 15 days to decide, extendable once. No federal rule says who bears the cost if it is missed: that is set by your plan documents and the provider's contract, so settle it before the date. An approval is not a promise to pay.
A planned procedure can fail on paper even when everything about the care goes to plan. The facility is in network, the physician is in network, the date is set, and a week later the plan says the procedure was never authorized. The bill that follows can be large, and the argument over whose job it was can take months. This guide is about the part of that story that is knowable in advance: what prior authorization is, which rules set the deadlines for a decision, what an approval does and does not cover, and which questions to put to the provider and the plan in writing before the date.
The rules cited here come from HealthCare.gov, the CMS Interoperability and Prior Authorization final rule fact sheet (CMS-0057-F), the Medicare Advantage regulations, the Department of Labor's claims procedure regulation, and the federal emergency services rule, all checked on October 22, 2026. This site covers prices and billing only. It does not say whether any test or treatment is needed, and the "medical necessity" the plan decides on is a coverage standard, not advice about your care.
What prior authorization is, and what it is not
HealthCare.gov's definition is short. Preauthorization is a decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Plans use the names prior authorization, prior approval and precertification interchangeably. The same page makes two points that matter for cost. Your plan may require it for certain services before you receive them, except in an emergency. And preauthorization is not a promise that the plan will cover the cost.
That last point separates two things people tend to merge. Authorization answers one question: does the plan agree the service meets its criteria? Payment depends on other questions that authorization does not settle, such as whether you were covered on the date of service, whether the provider was in network, whether the claim was coded as authorized, and whether your cost sharing applies. Authorization changes the plan's answer to the first question and nothing else. The cost-sharing side of the story is in the guide on estimating your cost with insurance, where the federal rule requires a plan's cost estimate to say if an item is subject to a prerequisite such as prior authorization.
Who asks, and who pays if it is missed
The most common question about prior authorization is also the one the law answers least. No federal rule says that a patient pays, or that a provider absorbs the cost, when a required authorization was not obtained. The allocation comes from the documents: the plan's benefit booklet, which says what you must do and what happens if you do not, and the provider's contract with the plan, which in many cases says the provider must obtain authorization for in-network services. This guide cannot read those documents for you. It can give you the questions that bring the answer out.
| Who | What to ask | Where the answer lives |
|---|---|---|
| The physician ordering the procedure | Do you submit the prior authorization request, and when? What code or codes will you request? | The practice's referral or surgery scheduling staff |
| The facility where it happens | Do you check authorization before the date, and what happens to my account if it is missing? | Facility pre-registration or patient financial services |
| Each separately billing group (anesthesia, pathology, imaging) | Does your service need its own authorization, or does it follow the procedure's? | The group's billing office; the plan |
| The plan | Does this code require prior authorization under my plan? What is the reference number once approved, and for what code, provider, place and dates? | Member services, the plan's website and the benefit booklet |
| The plan, about responsibility | If an in-network provider fails to obtain a required authorization, what does the plan's booklet say about my cost sharing? | The benefit booklet; ask for the page in writing |
| The provider, about responsibility | If the authorization is missed, will you bill me, or hold me harmless? | The provider's billing office; ask for it in writing |
The last two rows are the two answers worth having in writing, because they are the ones that decide who pays. Do not rely on a phone answer from a scheduler. If the provider says it will bill you in that case, you have learned the risk is yours, and you can decide whether to ask the plan to confirm approval before the date, or reschedule.
A rule that does exist, for Medicare Advantage, shows what a binding approval can look like. Under 42 CFR 422.138(c), if the plan approved a covered item or service through a prior authorization or pre-service determination, it may not deny coverage later on the basis of lack of medical necessity and may not reopen the decision except for good cause or if there is reliable evidence of fraud or similar fault. That protection is specific to the approved service and to medical necessity. It does not cover, for example, a denial because the person was not enrolled.
Which rules govern the deadline for a decision
There is no single federal clock for prior authorization decisions. Which one applies depends on the kind of coverage. The table sets out the rules that could be yours, in the order of how many people they reach.
| Coverage type | Standard (non-urgent) decision | Urgent or expedited decision | Source |
|---|---|---|---|
| Group health plan (employer plan, subject to the Department of Labor claims rule), pre-service claim | Within a reasonable period, not later than 15 days after receipt; one extension of up to 15 days if the plan notifies you before the first 15 days end and explains why. If it needs information from you, you get at least 45 days to supply it | As soon as possible, not later than 72 hours after receipt; if information is missing, the plan must tell you what within 24 hours and give you at least 48 hours to supply it | 29 CFR 2560.503-1(f)(2) |
| Medicare Advantage plan, standard organization determination for a service subject to prior authorization rules | 7 calendar days after receiving the request (beginning January 1, 2026); 14 calendar days for a service not subject to those rules; an extension of up to 14 days is allowed in listed circumstances | No later than 72 hours after receiving a request that the plan approves for expedited handling (42 CFR 422.572) | 42 CFR 422.568(b) |
| Payers covered by the CMS Interoperability and Prior Authorization final rule: Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans and CHIP managed care entities | 7 calendar days | 72 hours | CMS fact sheet, CMS-0057-F |
| Qualified health plan issuers on the federally-facilitated Exchanges | Covered by CMS-0057-F's other provisions, but not by the 72-hour and 7-day timeframes, which exclude them | Not applicable under that rule; the group and individual claims rules still apply | CMS fact sheet, CMS-0057-F |
| Original Medicare | Mostly not a prior authorization program, with two exceptions. A nationwide hospital outpatient department program (42 CFR 419.83) requires prior authorization, requested by the provider, for listed service categories: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation from July 1, 2020; cervical fusion with disc removal and implanted spinal neurostimulators from July 1, 2021; and facet joint interventions from July 1, 2023. And CMS's WISeR model, from January 1, 2026 to December 31, 2031 in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington, uses prior authorization or pre-payment review for selected services | The WISeR page does not state decision deadlines; the regulation list is in 419.83 | 42 CFR 419.83; CMS Innovation Center, WISeR |
Sources: 29 CFR 2560.503-1; 42 CFR 422.568; CMS fact sheet on the Interoperability and Prior Authorization final rule (CMS-0057-F); CMS Innovation Center WISeR page. Checked October 22, 2026. Your state may add rules for insured plans that are not covered here.
Read the rows against your own plan. If you have an employer plan that is self-funded, the Department of Labor claims rule is the one that applies most directly, and the plan's summary plan description will state its own time limits. If you have a Marketplace plan, ask the issuer for its timeframes in writing; the 72-hour and 7-day rule in CMS-0057-F does not apply to qualified health plan issuers on the federally-facilitated Exchanges. In Medicaid, the rule covers fee-for-service programs and managed care plans, and your state agency can tell you which applies to you. The rule excludes drugs. And it describes the minimum: a plan can respond faster.
CMS-0057-F adds two things that affect denials. Starting in 2026 the payers it covers must give a specific reason for a denied prior authorization decision, and they must publicly report certain prior authorization metrics each year on their websites, the first set due March 31, 2026. API requirements, which let providers and patients exchange prior authorization information electronically, are generally due January 1, 2027, with exact dates by payer type. The practical effect for you, in 2026, is the denial reason: ask for it in writing.
A calendar worked backward from the procedure date
Because the decision can take days to weeks, the time to find out about prior authorization is when the procedure is scheduled, not the week before. The dates below are hypothetical, and any year with the same weekdays works. They show how the clocks in the table translate into a schedule, for a non-urgent procedure with an employer plan.
| Hypothetical date | Step | Clock |
|---|---|---|
| Monday, March 2 | Procedure scheduled for April 20. You ask the plan whether the code requires prior authorization and who submits it | None yet |
| Friday, March 6 | Practice submits the request with the code, facility and date | 15-day clock for a group health plan begins on receipt |
| Saturday, March 21 | Fifteenth day after receipt: the plan's decision is due, unless it sent a timely notice of a 15-day extension | Extended deadline would be April 5 |
| Monday, March 23 | If no decision, you call the plan and the practice and ask for the status and reference number in writing | Time remains for an appeal if the decision is a denial |
| By April 6 | You hold an approval number, with the code, provider, facility, dates and units it covers, or a denial with a stated reason | About two weeks before the procedure |
| April 20 | Procedure date | Authorization has to match what is performed |
The arithmetic is simple, but it is also the reason many authorization problems are really scheduling problems. If a denial arrives with two days to spare, there is no time for an appeal of a non-urgent denial, and the choices are to proceed at risk, delay, or ask whether an expedited path applies. A denial that arrives with a month to spare leaves time for the plan's internal appeal, which is described in the guide to appealing a health insurance denial.
What a good approval looks like
An approval is useful in proportion to its detail. Ask for the authorization in writing and check each of these against what the provider told you will happen.
- Reference or authorization number. The number to quote if a claim denies for missing authorization.
- The codes approved. If the authorization is for one CPT code and a different code is billed, the match can fail. Ask the provider what code or codes the facility and the physician will bill, and whether the request covered both.
- The provider and place. An authorization may be tied to a named provider or facility. A change of facility can need a new one.
- Dates. Approvals often have a validity window. If the date moves, ask whether the approval moves with it.
- Units or visits. For therapy or repeated services, how many.
- The statement of what it does not decide. Many approvals say they are not a guarantee of payment, consistent with the HealthCare.gov definition.
If the procedure changes on the day, for instance an additional service is performed, ask afterward whether the additional service needed its own authorization. The guide to questions to ask billing before your procedure covers the day-of-change question for the price as well.
Emergencies and urgent care
Emergency care is the exception. The federal rule for plans that cover emergency department services requires them to cover emergency services without the need for any prior authorization determination, even if the services are provided on an out-of-network basis, and without regard to whether the provider is in network. Do not delay emergency care to ask about authorization. After an emergency, the visit's billing is a separate set of questions, covered in the guide to ER visit levels.
Urgent but non-emergency care is where the expedited clocks come in. Group health plans must decide an urgent care claim as soon as possible, not later than 72 hours, and the CMS rule uses 72 hours for expedited requests. Whether a claim is urgent depends on the clinical picture, which is for your clinician and the plan to decide. If your clinician believes a delay would harm you, say so to the practice, and ask them to mark the request expedited.
When authorization is denied or missing
- Get the reason in writing. A group health plan's denial notice must give the specific reasons, reference the plan provisions, describe any additional material needed and explain the review procedures and time limits. For the payers covered by CMS-0057-F, the denial must include a specific reason.
- Ask whether more information would change the answer. Many denials are for missing documents, not a final decision.
- Ask the provider to appeal or to request a peer discussion. The provider's office usually has a process for this. The plan's denial notice describes yours.
- File your own appeal on time. The deadlines are in the appeals guide linked above.
- Hold the bill. If care was already delivered and the claim was denied for missing authorization, ask the billing office to place the account on hold while the plan and provider sort it out, and do not pay a collector until the claim is resolved. The guide to a medical bill in collections explains your rights if it goes that far.
- Ask who bears the cost. Return to the table at the top, and ask the plan to cite the provision.
These steps do not decide the outcome. They protect your ability to dispute it.
Prior authorization for Original Medicare patients
People with Original Medicare are mostly outside the prior authorization system described above, but not entirely. First, the Medicare regulation at 42 CFR 419.83 lists hospital outpatient department service categories that require prior authorization nationwide. The list in the regulation, checked October 22, 2026, is blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation (service dates from July 1, 2020), cervical fusion with disc removal and implanted spinal neurostimulators (from July 1, 2021), and facet joint interventions (from July 1, 2023). The hospital requests the authorization, and the regulation says CMS adopts and updates the list through rulemaking, with technical code updates posted on the CMS website, so ask the hospital whether your service is on the current list. Second, CMS runs a model that applies prior authorization to selected services in six states. CMS's WISeR page says the model, which runs from January 1, 2026 through December 31, 2031 in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington, uses technology and human clinical review to check medical necessity for selected Original Medicare services before payment. Providers and suppliers in selected regions can submit a request or go through post-service, pre-payment review, and a claim without prior authorization gets medical review before payment. The page names skin and tissue substitutes, implantation of electrical nerve stimulators, and knee arthroscopy for knee osteoarthritis among the selected services, and excludes inpatient-only services, emergency services and services where delay would pose a substantial risk to patients. The model does not apply to Medicare Advantage. If you live in one of those states, ask the provider whether your service is on the list and who submits.
The cost side of Original Medicare is separate. The 20 percent share and the hospital copayment for a covered outpatient service are worked through in what Medicare patients pay for an outpatient procedure, and the form a provider gives when it expects Medicare to deny a service is the subject of the Advance Beneficiary Notice guide.
Mistakes that cause authorization problems
- Assuming the scheduler checked. Ask who submitted, on what date, for which code.
- Treating a verbal "you're approved" as an approval. Get the reference number and the details in writing.
- Authorizing one layer. The surgeon's approval may not cover the facility's, or anesthesia's.
- Letting the date, place or code change. Ask whether any of them requires a new request.
- Waiting for the bill to find out. By then, the clocks for appeal are already running.
- Assuming "authorized" means "covered at full benefit." Your deductible, coinsurance and network rules still apply.
Authorization: what people ask
What is prior authorization?
HealthCare.gov defines preauthorization as a decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. It is also called prior authorization, prior approval or precertification. Your plan may require it for certain services before you receive them, except in an emergency, and it is not a promise that the plan will cover the cost.
Who is supposed to request prior authorization, me or the doctor?
In most plans the ordering or treating provider submits the request, but the plan's documents and the provider's contract with the plan decide who is responsible. No federal rule assigns the cost of a missed authorization to the patient or to the provider, so ask both the provider and the plan, and ask who bears the cost if it is missed.
How long does a plan have to decide?
It depends on the kind of plan. A group health plan must decide a non-urgent pre-service claim within 15 days, with one 15-day extension, and an urgent claim within 72 hours. A Medicare Advantage plan must decide a standard request subject to prior authorization within 7 calendar days from 2026. Under the CMS Interoperability and Prior Authorization final rule, certain payers must decide within 72 hours for expedited and 7 calendar days for standard requests.
Does an approval guarantee payment?
Not in general. HealthCare.gov says preauthorization is not a promise your plan will cover the cost. In Medicare Advantage, a plan that approved a service through prior authorization may not later deny coverage on the basis of lack of medical necessity, except for good cause or fraud or similar fault. Eligibility, network status and coding still matter.
Is prior authorization required for emergency care?
No. Federal rules require a plan that covers emergency services to cover them without any prior authorization determination, even if they are provided out of network.
What if I need the procedure soon and the standard time is too long?
Ask the provider whether it can request an expedited decision. Group health plan rules set 72 hours for urgent care claims, and the CMS rule sets 72 hours for expedited requests at the payers it covers. Whether your situation qualifies as urgent is a determination for the plan and your clinician, not something this site can assess.
Rules and pages relied on
- HealthCare.gov glossary, Preauthorization. Checked October 22, 2026.
- CMS, CMS Interoperability and Prior Authorization final rule (CMS-0057-F) fact sheet: impacted payers, 72-hour and 7-day decision timeframes (excluding qualified health plan issuers on the federally-facilitated Exchanges), denial reasons, metrics reporting, API dates, drug exclusion. Checked October 22, 2026.
- eCFR, 42 CFR 422.568 (standard organization determinations, 7 and 14 calendar days) and 42 CFR 422.138 (prior authorization in Medicare Advantage). Checked October 22, 2026.
- eCFR, 29 CFR 2560.503-1 (group health plan claims procedures: pre-service and urgent care claims, content of denial notices). Checked October 22, 2026.
- eCFR, 42 CFR 419.83, hospital outpatient department services requiring prior authorization. Checked October 22, 2026.
- eCFR, 45 CFR 147.138, coverage of emergency services without prior authorization. Checked October 22, 2026.
- CMS Innovation Center, WISeR model. Checked October 22, 2026.
General billing and coverage information, not legal or medical advice. Your plan documents and written answers from your plan control. Prices only on this site: no diagnosis or treatment advice. Confirm your price in writing before service.
If you already have a denial in hand, the appeal guide sets out the filing windows and what to put in the letter, and it is the right next read while the clock is running.