A medical review is a formal process to determine the necessity, appropriateness, and quality of medical care provided or proposed for a patient. These reviews are initiated by third-party payers, such as private health insurance companies or government programs, to ensure treatments align with established clinical guidelines and coverage policies. The outcome directly impacts whether a service will be covered, a claim will be paid, or a patient will be approved for benefits.
Defining Timelines by Review Type
The duration of a medical review varies widely based on its purpose and governing regulations, ranging from hours to months.
Prior Authorization (PA)
The shortest review is often a Prior Authorization (PA) for an urgent service. Major health plans are required to process urgent PAs within 24 to 72 hours if a delay could seriously compromise the patient’s health. Standard PA requests for non-urgent services, such as scheduled procedures, are generally processed within 7 to 15 calendar days, depending on the payer and applicable guidelines.
Claims Reviews
Standard claims reviews occur after a service has been rendered and focus on payment. Many employee benefit plans governed by the Employee Retirement Income Security Act (ERISA) have up to 15 days to make a determination once all necessary information is received. New federal rules for government-regulated plans will standardize a seven-day response time for electronic prior authorization requests starting in 2026.
Appeals Reviews
Reviews involving a denial of coverage, known as Appeals Reviews, take substantially longer due to their multi-layered nature. An internal appeal, where the patient asks the insurer to reconsider its decision, often takes 30 to 60 days for a final determination. If the internal appeal is denied, the case can move to an external review by an Independent Review Organization, extending the timeline further.
Government or Disability Reviews
The longest review periods are associated with Government or Disability Reviews, such as those for Social Security Disability Insurance. These reviews assess complex, long-term medical histories and vocational factors, often resulting in processing times measured in months or even years. This extended duration is due to the volume of applications and the requirement to gather extensive historical medical documentation from multiple sources.
Standard Steps in the Medical Review Process
The medical review process follows a predictable sequence of actions that consume time.
Submission and Intake
The review begins with Submission and Intake, where the request is formally logged into the administrative system. This step includes an initial check to ensure all required fields and forms have been completed.
Documentation Gathering
The next phase is Documentation Gathering, which is often the most time-intensive part of the process. The reviewer must collect all relevant clinical information, including physician notes, laboratory results, and imaging reports, to build a complete case file. This collection often involves communication with multiple healthcare facilities.
Clinical Assessment
Once compiled, the file moves to Clinical Assessment, where a nurse or non-physician reviewer evaluates the request against established clinical criteria. This initial assessment determines if the request meets basic medical necessity guidelines. Cases that do not clearly meet the criteria are forwarded for expert evaluation.
Physician Review and Decision
The final clinical stage is the Physician Review, where a medical director or specialist physician reviews the case file, particularly if the initial assessment flagged a potential issue. This medical professional applies their expertise to the evidence and the payer’s policies. The process concludes with Decision Formulation and Notification, where the final determination is recorded and the patient and provider are informed of the outcome.
Factors That Cause Delays
Multiple variables can disrupt the standard timeline and extend a medical review beyond the expected duration.
Incomplete Documentation
The most frequent cause of delay is the submission of Incomplete or Missing Documentation from the provider’s office. If the initial request lacks necessary clinical notes or specific codes (ICD or CPT), the reviewer must pause the process to request the missing information. The clock restarts only once the required data is received.
Case Complexity
The Complexity of the Case is a significant factor, as reviews involving multiple co-morbidities, experimental treatments, or rare conditions require intensive scrutiny. A simple service review may take hours, but a case requiring the analysis of voluminous medical records spanning several years will require many more weeks for a thorough assessment. The volume of the patient’s medical chart directly correlates with the time needed for analysis.
Coordination Issues
Reviews can also be delayed by the need for a Peer-to-Peer Consultation, where the reviewing physician must speak directly with the treating physician. This consultation is often required before a request can be denied, but coordinating the schedules of two busy physicians can add several days or weeks to the timeline. Additionally, Administrative Backlogs and High Volume within the reviewing organization can slow down processing, especially during peak periods.
Expediting a Medical Review
Patients and providers can take proactive steps to minimize the wait time for a medical review decision.
Requesting an Expedited Review
The most direct method is requesting an Expedited Review. This option is reserved for cases where the standard timeframe could jeopardize the patient’s life, health, or ability to regain maximum function. The request must include clear documentation from the treating physician justifying the immediate need and explaining the harm that would result from a delay.
Ensuring Complete Documentation
The most effective way to prevent administrative delays is to ensure Proactive and Complete Documentation Submission from the outset. Provider staff should use payer-specific checklists to verify that all required forms, clinical notes, and supporting diagnostic reports are submitted initially. Accurate and complete information avoids the back-and-forth communication that consumes the most time in a review cycle.
Timely Follow-Up
Provider staff also plays an important role in Timely Follow-Up and response to information requests. By consistently monitoring the status of a pending review and quickly providing supplementary details requested by the payer, the provider can keep the case moving. Patients can assist by maintaining open communication with their provider’s office and the payer to track the status.