What to Do If Your Prior Authorization Is Denied
When your doctor says you need treatment but your insurance says “no,” it can feel overwhelming. Prior authorization denials are frustrating, but they are also common. Fortunately, you have options, and acting quickly can make a difference.
What Is Prior Authorization?
Prior authorization is a requirement from your health insurance company to approve certain services—such as procedures, medications, or specialist visits—before you receive them. If you skip this step or it’s denied, your insurer may refuse to pay, and you could be left with the full cost.
Why Prior Authorization Is Denied
Common reasons include:
- The insurer claims the treatment is not medically necessary.
- There was an error in the diagnosis or billing code.
- The provider is considered out-of-network.
- The documentation submitted was incomplete or unclear.
- The insurer misapplied internal coverage rules.
Steps to Take After a Denial
- Get the Denial in Writing
Ask for a denial letter if you haven’t received one. This letter should explain why your request was denied and inform you of your appeal rights and deadlines.
- Contact Your Provider’s Office
Doctors and staff are often familiar with prior authorization denials. They may correct coding errors or submit additional medical records to strengthen your case.
- File a Medical Necessity Appeal
If the denial is upheld, you can submit a formal appeal that explains why the treatment is necessary. Include:
- A letter of medical necessity from your doctor
- Supporting medical records
- Published research or clinical guidelines, when available
- Ask for an Expedited Appeal (if time-sensitive)
If your health could be seriously harmed by waiting, you may qualify for an expedited review. Insurers must respond within 72 hours for urgent cases, as mandated by federal and ACA rules.
You Don’t Have to Navigate This Alone
Handling a prior authorization denial takes time, precision, and persistence. At Appeal Healthcare, we help patients and families overcome these roadblocks by preparing comprehensive appeal packets, collaborating with providers, and advocating for timely action from insurers within legal deadlines.
We understand the importance of timely treatment, and we are here to help you move forward with clarity and support.
Need help with your denied authorization?
Contact us today to schedule a complimentary consultation and discover how we can help you with your next steps.
Ethics and compliance notes for Ohio and Kentucky
Attorney Advertising. This page provides general information. It is not legal advice and does not create an attorney-client relationship. Every situation is fact-specific. Do not rely on this content without advice from a lawyer who knows your facts. Past results do not predict future results.
Responsible lawyer and office address: Frank M. Mungo Attorney at Law, 7310 Turfway Road, Suite 550, Florence, Kentucky 41042. Mr. Mungo is licensed in Kentucky and Ohio.
