What Should You Do If Prior Authorization Is Denied?
A denied prior authorization request can feel like a dead end, especially when a procedure is already scheduled. In practice, it’s usually the start of a defined process rather than a final decision.
The short answer
When a prior authorization request is denied, the general next steps are to get the specific denial reason in writing, gather supporting medical records and documentation from the treating provider, and file an internal appeal with the insurer before the stated deadline. Many denials trace back to missing or incomplete information rather than a firm judgment that the treatment isn’t warranted.
Start by getting the exact reason
Denial notices are required to include a reason, but that reason can be brief or use technical language. Requesting a fuller explanation, in writing, of which specific coverage criteria weren’t met makes it possible to address the actual gap rather than guessing. This is closely tied to how an insurer decides whether a treatment is medically necessary in the first place, since many denials stem from that determination.
Loop in the provider’s office early
The treating provider’s office is often the one best positioned to supply additional clinical notes, test results, or a more detailed explanation of why the treatment fits the diagnosis. Since the original request came from that office, it typically has the fastest path to resubmitting stronger documentation.
Understand the appeal path and its deadline
Most plans allow a formal internal appeal, with a specific window in which it has to be filed. Missing that deadline can close off the option to challenge the decision through the plan’s own process. The mechanics of that process, including timing and what to include, are covered in more detail in how to appeal a prior authorization denial.
Consider whether a peer-to-peer review applies
Some insurers offer a peer-to-peer review, a direct conversation between the treating physician and a reviewing physician at the insurer, as a faster way to resolve a dispute before or alongside a formal written appeal. Not every plan offers this option, and it typically has to be requested rather than happening automatically.
Keep a paper trail
Throughout the process, saving copies of the denial letter, all correspondence, and any documents submitted creates a record that’s useful if the appeal needs to go further, including to an external review in some cases. Dates matter here, since appeal windows are often measured in a specific number of days from the date of the denial notice.
A practical habit
Treating a denial as a documentation problem to solve, rather than a closed door, tends to be the more productive way to approach it. Getting the specific reason in writing, working with the provider’s office on supporting records, and tracking appeal deadlines closely are the steps that show up across most denial-and-appeal processes, even though the fine print varies by plan.