What It Means
Prior authorization is a decision by your health planHealth insuranceA plan you pay a premium for that covers part of your medical costs, while you pay your own share through a deductible, copays and coinsurance. See more, made before you get certain care, that a service, treatment plan, prescription drug or piece of durable medical equipment is medically necessary. HealthCare.gov's glossary says it's also called preauthorization, prior approval or precertification. An approval isn't a promise that the plan will pay, so your coverage and your share of the cost still need checkingChecking accountA bank or credit union account for everyday money going in and out, used by debit card, checks, transfers and direct deposit. See more.
Try It: Which Prior Authorization Deadlines Apply to Your Plan?
Pick your type of plan to see what CMS's prior authorization rule requires from January 1, 2026.
Urgent request: decision within 72 hours
Standard request: decision within 7 calendar days
A denial must come with a specific reason.
A denial must come with a specific reason. The 72-hour and 7-day deadlines don't apply to these plans.
Not among the plans this rule covers. Your plan's documents give its own timelines.
How People Say It
- "The MRI needs a prior auth before they'll schedule it."
- "We're still waiting on insurance to approve the prescription."
- "Did the office send the precert yet?"
The Breakdown
What the rule says. Your plan's documents show which care needs its approval first. HealthCare.gov's glossary describes prior authorization as the plan deciding the care is medically necessary, and warns that an approval isn't a promise of payment.
CMS's 2026 deadlines. Under the Interoperability and Prior Authorization Final Rule (CMS-0057-F), issued in January 2024, these plans must answer prior authorization requests within set times starting January 1, 2026:
| Plan | Urgent request | Standard request |
|---|---|---|
| Medicare Advantage | 72 hours | 7 calendar days |
| Medicaid and CHIP fee-for-service | 72 hours | 7 calendar days |
| Medicaid managed care and CHIP managed care | 72 hours | 7 calendar days |
The same rule requires a specific reason for a denial from those plans and from Qualified Health Plan issuers on the Federally-Facilitated Exchanges, which CMS left out of the deadline requirement.
Who it applies to. Anyone whose plan requires approval for the care they need. The CMS deadlines apply only to the plans in the table.
Documents and details to have ready
- Your insurance card and member ID
- The name of the service, drug or equipment, and the doctor ordering it
- The date the request went in, and any reference number
- The plan's written decision, and the reason if it's a denial
Official source. HealthCare.gov's glossary and CMS's fact sheet on CMS-0057-F, checked October 2026.
Good to Know
Ask your doctor's office before a planned procedure, a new prescription or medical equipment whether your plan needs approval first, and get the decision in writing before the date. Since an approval isn't a guarantee of payment, also check that the provider is in your network and what your share will be. If a request is denied, the rule above requires a specific reason from the plans it covers; your plan's documents explain how to appeal.
FAQ
What is prior authorization for medication?
Some plans need to approve certain prescription drugs before they'll cover them. HealthCare.gov's glossary includes prescription drugs among the things a plan can review for medical necessity first.
How long does prior authorization take?
It depends on the plan. Under CMS-0057-F, from January 1, 2026, Medicare Advantage, Medicaid and CHIP plans must decide within 72 hours for urgent requests and seven calendar days for standard ones; other plans set their own timelines.
Does prior authorization mean my plan will pay?
No. HealthCare.gov's glossary says it isn't a promise the plan will cover the cost, so check your coverage and cost-sharing as well.
Do It in Buhata
Tasks, Reminders
Add a Task for each pending approval with the request date and reference number, and set a Reminder to call the plan if no decision has come by the deadline.
Open BuhataRelated Terms and Categories
- In-network
Describes a doctor, hospital or other provider that has a contract with your health plan, so you usually pay less for covered care than you would outside the network.
- Explanation of benefits
A statement from your health plan, not a bill, that shows what a provider charged for a visit, what the plan paid and what you may owe.
- Health insurance
A plan you pay a premium for that covers part of your medical costs, while you pay your own share through a deductible, copays and coinsurance.
- Out-of-pocket maximum
The most you pay in a plan year for covered in-network care through deductibles, copays and coinsurance, after which the plan pays covered benefits in full.
- Out-of-network
Describes a provider that has no contract with your health plan, so the plan pays less or nothing for the care and you may be billed more.
- Medical debt
Money owed for health care, such as hospital, doctor, lab or ambulance bills; unpaid bills can go to collections and, in some cases, onto credit reports.
Sources
HealthCare.gov Glossary, "Preauthorization"; HealthCare.gov Glossary, "Prior authorization"; Centers for Medicare & Medicaid Services, "CMS Interoperability and Prior Authorization Final Rule CMS-0057-F" (fact sheet); CMS, "CMS Finalizes Rule to Expand Access to Health Information and Improve the Prior Authorization Process" (press release)
- www.healthcare.gov/glossary/preauthorization
- www.healthcare.gov/glossary/prior-authorization
- www.cms.gov/newsroom/fact-sheets/cms-interoperability-prior-authorization-final-rule-cms-0057-f
- www.cms.gov/newsroom/press-releases/cms-finalizes-rule-expand-access-health-information-improve-prior-authorization-process
Last updated .