How prior authorization works, for hormones as well as surgery
Before a plan pays for many things — surgery, but also hormones, blockers, electrolysis and some mental-health visits — someone has to ask it to agree in advance. That request is prior authorization. It is a plan rule rather than a law, so whether you need one depends on your plan and your codes.
Deadline. For employer, marketplace and individual plans: a decision on a non-urgent pre-service request is due within a reasonable time appropriate to the medical circumstances and NOT LATER THAN 15 DAYS after the plan receives it, extendable once by up to 15 more — 29 CFR 2560.503-1(f)(2)(iii)(A), read from the regulation. If a physician says waiting would harm you it is urgent, and 29 CFR 2590.715-2719(b)(2)(ii)(B) cuts that to 72 hours. Medicaid and Medicare run their own decision timeframes, and Medicaid's is SHORTER — see below.
Applies to All plan types, though the decision timeframes below are the commercial ones — Medicaid and Medicare set their own. Whether prior authorization is required at all is set by your plan document rather than by federal law.
Who submits the request, and what your job is in each case
For most surgery your surgeon's office submits the authorization, not you. That is the single most useful fact on this page, because it changes your job from filling in a form to making sure someone else's form is complete, sent, and answered — which is work nobody assigns you.
Applies to All plan types. Who submits is set by the plan's process and the kind of service, not by your plan type.
Where you can actually intervene before a decision is made
There are about six points in the process where something you do changes the outcome, and all of them are before anyone decides. Most are unglamorous: getting a document, sending a copy, writing down a date. None of them require you to argue medicine.
Applies to All plan types. The intervention points are the same; who you send things to differs by plan.
Preparing before there is anything to appeal
If your surgery is still months away, most of the work that decides the outcome happens before anyone denies anything. The prior authorization has a short window, but the record it rests on takes about a year to build. This is the order to build it in.
Deadline. Work backward from your surgical practice's financial-clearance cutoff, not from your insurer's timelines. Many practices cancel a date if coverage is not resolved two to four weeks beforehand, which makes that the real deadline. Ask your practice what theirs is, in writing, before you plan anything else.
Applies to Anyone with a surgery date ahead of them, or on a waitlist. If you are already holding a denial, start with the denial pages instead — this page is about the record you wish you had.
Getting paid back after you have already paid
Sometimes you pay first and claim afterwards — an out-of-network surgeon, an electrologist who does not bill insurance, care you got while an appeal dragged. Whether you get that money back depends almost entirely on your plan type, and the law is genuinely on your side in some of these and genuinely not in others.
Deadline. For employer, marketplace and individual plans the appeal window after a denied reimbursement claim is the same 180 days from RECEIPT. The one that catches people first is different: your plan's TIMELY FILING limit for submitting the claim at all, which is set by the plan and is often far shorter. Find that number before anything else.
Applies to All plan types, and the differences here are larger than anywhere else on this site. Read your own row before you read anything else.
Last updated 2026-08-12 · Not legal or medical advice