Prior authorization means your Medicare Advantage plan has to approve a service, test, or item before you get it, or the plan may not pay. Starting in 2026, the Centers for Medicare & Medicaid Services (CMS) requires Medicare Advantage plans to make prior authorization decisions on medical items and services within 72 hours for urgent requests and 7 calendar days for standard requests, and to give a specific reason for any denial. If your plan says no, you can appeal, and you can ask for a fast decision if waiting could seriously harm your health.
What is prior authorization?
Many Medicare Advantage plans require approval in advance for certain care. Examples can include some imaging scans, surgeries, skilled nursing facility stays, home health, durable medical equipment, and some drugs given in a doctor's office. Each plan sets its own list.
Original Medicare uses prior authorization much less often. Medicare.gov's comparison of Original Medicare and Medicare Advantage notes that Medicare Advantage plans may require you to get approval before some services are covered.
Usually your doctor's office asks the plan for approval. You don't have to file it yourself, but it helps to know where things stand.
How fast does my plan have to decide?
CMS's Interoperability and Prior Authorization Final Rule (CMS-0057-F) set these timeframes, which apply to Medicare Advantage plans starting in 2026:
- Urgent (expedited) requests: a decision within 72 hours.
- Standard requests: a decision within 7 calendar days.
The rule covers medical items and services, not prescription drugs. CMS also requires plans to give a specific reason when they deny a prior authorization request. That reason matters, because it tells you and your doctor what to fix or argue in an appeal.
What should I do if prior authorization is denied?
1. Read the denial notice. Look for the reason and the deadline to appeal. In Medicare Advantage, a coverage decision is called an "organization determination."
2. Call your doctor's office. Ask:
- "Did you get the denial, and what reason did the plan give?"
- "Can you send more records or talk to the plan's medical director?"
- "Is there another covered option that would work?"
Sometimes the fix is simply missing paperwork.
3. Appeal. The first level of appeal in a Medicare Advantage plan is a "reconsideration" by the plan. Medicare.gov lists how long the plan has to answer:
| Type of appeal | Plan's deadline |
|---|---|
| Pre-service appeal (care you haven't gotten yet) | 30 days |
| Payment appeal (care you already got) | 60 days |
| Part B drug appeal | 7 days |
| Fast appeal | 72 hours |
Medicare.gov notes these can be extended by up to 14 days in some cases.
4. Ask for a fast appeal if your health is at risk. The plan must decide within 72 hours if it finds, or your doctor tells the plan, that waiting for a standard decision could seriously jeopardize your life, health, or ability to regain maximum function.
5. Keep going if the plan says no again. If the plan doesn't decide fully in your favor, the appeal is sent on to an independent reviewer. Our article on Medicare Advantage appeals walks through the deadlines and what to say.
What if I already got the care and now there's a bill?
If you got care without prior authorization and the plan won't pay, ask:
- Did a plan doctor send you? Medicare.gov describes "plan directed care." If a plan provider refers you for a service, or to a provider outside the network, without getting an organization determination first, you may be protected. In that case you should only have to pay your plan's usual cost sharing.
- Was it an emergency? As a general rule, plans can't require prior authorization for emergency care. Check your plan's Evidence of Coverage and the denial notice.
- Was the claim coded correctly? Sometimes approval was given but the claim was billed under a different code.
You can file a payment appeal with your plan if you think it should pay.