How long the plan has to decide
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.
If you are on another plan
Is your coverage Medicaid or CHIP?
Then the deadline above is not the one that governs. Yours is SHORTER than the commercial one, not longer: a standard decision is due within state-set limits that may not exceed 7 calendar days for rating periods starting on or after 1 January 2026, and 14 before that, under 42 CFR 438.210(d)(1)(i). Expedited is 72 hours, which the plan may extend by up to 14 days if you ask or if it justifies the delay.
Go to the Medicaid managed-care decision timeframesIs your coverage Medicare?
Then the deadline above is not the one that governs. Yours is 14 calendar days for a standard organization determination, and 72 hours for a Part B drug request, under 42 CFR 422.568(b). Original Medicare mostly pays after the fact rather than authorising in advance, so there is often no pre-service decision to wait on at all.
Go to the Medicare Advantage decision timeframesIs your plan through a state or local government, a public school district, a church, or a federal civilian agency? Then this one genuinely varies. Plans like yours sit outside the federal rule above, and many adopt similar timelines voluntarily — but nobody guarantees it. The deadline printed on your denial letter and your plan document govern, not this page.
Go to what governs a church, government or federal employee planWhat to do
Find out whether a request is even required
Prior authorization is not universal. Ask your plan, in writing, whether the specific codes that will be billed require prior authorization, and ask for the medical policy that governs them by name and number. Get the codes from whoever is billing — a surgeon's office for a procedure, the prescriber or the pharmacy for a medication — because the answer is code-specific and a general question gets a general answer.
Find out WHO is submitting it
This is the question almost nobody asks, and the answer decides what your job is for the next several months. For surgery it is usually the surgeon's office. For medication it is usually the prescriber. For a few things — out-of-network exceptions, some reimbursement claims — it is you. Ask the clinic directly: are you submitting this, or am I?
Read the plan's own criteria before the request goes in
The medical policy lists what the plan says it requires. Your clinicians can only answer criteria they have seen. Handing them the policy before they write, rather than after a denial, is the single highest-value thing you can do, and it costs one email.
Confirm it was actually submitted, and get the date
Requests get prepared and not sent more often than anyone admits. Ask the clinic for the date of submission and the reference number the plan gave back. If nobody can produce a reference number, the plan may not have it. Write the answer down.
Track the clock yourself
Plans have to decide within a stated window. Nobody will tell you it has passed. If it does, that is not merely annoying — a missed timeframe can itself become an argument, and it is one of the few things you can prove without a clinical debate.
Read the approval as carefully as you would read a denial
An approval names specific codes, a specific facility, sometimes a specific surgeon, and an expiry date. Anything not named is not approved. This is where a surprise bill comes from months later, and it is fixable in the week the letter arrives.
Medication runs on a different track from surgery
Most plans have two separate benefits and this care touches both. Surgery, office visits and procedures go through the MEDICAL benefit. Anything a pharmacy fills — hormones, blockers — usually goes through the PHARMACY benefit, which is often run by a different company, with its own criteria, its own form and its own appeal address. The card in your wallet often carries two phone numbers for exactly this reason.
That split is why a refused prescription rarely looks like a denial. There is usually no letter: there is a code at the counter and a pharmacist saying it did not go through. Ask them to read you the rejection code and tell your prescriber what it says. The code names what the plan wants — a prior authorization, a different formulation, or a documented trial of something cheaper first, which is called step therapy.
Hair removal sits in a third, more awkward place. Depending on the plan it is a medical benefit, an outright cosmetic exclusion, or covered only as part of a surgical episode when it is preparing a graft site. Worth asking which one it is before booking a course of it rather than after.
What an approval does not mean
An authorization says the plan agrees the service is covered for you. It does not promise what you will pay, it does not bind a provider who is out of network, and it does not survive a change of surgeon, facility or date without being updated. The anaesthesiologist and the assistant surgeon are frequently not covered by the same authorization as the surgeon.
So ask two more questions once you have it: which providers does this cover, and when does it expire. Both answers belong in writing.
Common questions
- Do I need prior authorization for hormone therapy?
- Sometimes, and it usually runs through the prescriber rather than through you. Many plans require prior authorization or step therapy for particular formulations. Ask your pharmacy what the rejection code says if a prescription does not go through — that code tells your prescriber exactly what the plan wants.
- The clinic said they submitted it weeks ago and nothing has happened.
- Ask the clinic for the submission date and the plan's reference number, then call the plan and ask them to confirm receipt against that number. A request the plan has no record of is the most common cause of a silence like this, and it is quick to fix once found.
- Can I submit the prior authorization myself if my clinic is slow?
- Usually not for surgery — plans generally take clinical requests from the treating provider. What you can do is supply the clinic with the plan's own criteria, chase the submission, confirm receipt with the plan, and document each step. If the delay is unreasonable, the contact log you built is what makes that provable.
Where to go next
Sources for the legal points on this page
- The ACA appeal framework: internal appeal, then binding external review
Federal — non-grandfathered group health plans and issuers · effective in force
29 CFR 2590.715-2719 — (b)(2)(ii)(B) urgent-care 72 hours, (b)(2)(ii)(F)(1) deemed exhaustion, (c)(2)(xi) state external review binding, (d)(2)(i) four-month federal external review window, (d)(2)(iv) immediate coverage on reversal; 29 CFR 2560.503-1 — (c)(2) no more than two appeals before civil action, (h)(3)(i) 180 days from receipt, (h)(3)(ii) independent reviewer, (h)(3)(iii) health professional on medical judgment
Status: settled · source-checked 2026-08-06 · primary source verified: 2026-08-06
- If a treating physician says the claim is urgent, the plan must treat it as urgent
Federal — ERISA-governed group health plans · effective in force
29 CFR 2560.503-1(m)(1)(iii) (physician determination controls), read against (m)(1)(ii) (otherwise a prudent-layperson standard applied by the plan) and (m)(1)(i) (what makes a claim urgent)
Status: settled · source-checked 2026-08-09 · primary source verified: 2026-08-09 (govinfo CFR XML, 2025 edition)
Also on this page, without a citation yet
- That your plan splits medical and pharmacy benefits, who administers each, and whether hair removal falls under either. All three are plan design rather than federal law and all three are answered by your plan document, not by us.
- Whether your plan's own timeframe is shorter than the federal ceiling. Many are, and the plan document is what binds them. The federal outer limits in the deadline block above were read from the regulation directly.
- That prior authorization is required for a given procedure. That is a plan-by-plan and code-by-code question with no federal answer. Ask your plan, in writing, naming the CPT codes.
These are specific and checkable and we have not yet checked them against a primary source. Treat them as a starting point rather than as settled, and do not put them in an appeal without confirming them.