Prior authorization is a necessary step in the healthcare process where a provider must receive approval from a payer before a specific service, medication, or item is covered. This requirement, often called pre-authorization or precertification, ensures that the requested care is medically necessary and cost-effective. Medicaid, a joint federal and state program providing health coverage to low-income adults, children, and people with disabilities, utilizes this process to manage utilization and costs. The time it takes to get this approval can vary significantly, depending on the urgency of the medical need and the administrative efficiency of the state or Managed Care Organization (MCO).
Standard Timeframes for Medicaid PA Decisions
The federal government sets maximum allowable timeframes for Medicaid Managed Care Organizations (MCOs) to process a standard prior authorization (PA) request. Currently, the regulation requires a decision to be made within 14 calendar days after the MCO receives the request for service. Many states or MCOs may choose to impose a shorter timeline for standard, non-urgent requests.
A new federal rule, set to take effect for most payers in January 2026, will cut this maximum allowable timeframe in half. For standard requests, this new mandate will require MCOs to make a decision within seven calendar days of receiving the request. The clock for this decision period starts only once the MCO receives a complete request. If the state Medicaid Fee-for-Service (FFS) program or MCO denies the request, they must also provide a specific reason for the denial.
State and Procedural Variables Influencing Duration
The standard decision timeframe often extends beyond the mandated 7 or 14 days due to procedural complexities, primarily concerning documentation. If a provider submits a request with incomplete clinical justification, the Medicaid entity or MCO will typically pause the review clock and request additional documentation. The provider must then gather and submit the necessary medical records, test results, or clinical notes to restart the review period.
This request for more information is a frequent cause of delay, as the provider may have a set time, such as 14 calendar days in some programs, to supply the missing paperwork before the request is automatically denied. The nature of the service requested can also affect the complexity of the review, as a request for an expensive specialty drug or a complex surgical procedure often requires more extensive clinical review. Since Medicaid is administered by each state, administrative differences exist, including varying levels of staffing and the use of electronic systems, which can influence the speed of processing.
Expedited Review Timelines
For situations where a delay in treatment could seriously jeopardize a patient’s life, health, or ability to regain maximum function, Medicaid offers an expedited review process. These urgent requests are subject to a much shorter, federally mandated timeline to ensure rapid access to necessary care. The MCO must make a decision and notify the provider and patient within 72 hours of receiving an expedited request.
The provider must clearly indicate and document the medical necessity of the urgency to qualify for this fast-track review. If the MCO determines that the request does not meet the criteria for urgency, they must notify the provider and process the request under the standard timeframe.
Timelines for Decisions on Appeals and Reconsideration
If an initial prior authorization request is denied, the Medicaid beneficiary or the provider on their behalf has the right to appeal the decision. The first stage is typically an internal reconsideration process conducted by the Managed Care Organization or the state Medicaid agency. For a standard internal appeal, the MCO generally has a maximum of 30 calendar days from the date of the request to issue a decision.
If the initial denial was for an urgent medical need, the appeal can also be expedited, with the MCO required to make a decision within 72 hours. If the internal appeal is unsuccessful, the beneficiary can then pursue a state fair hearing, which is an external review conducted by an administrative law judge. The state agency must take final administrative action on the fair hearing within a set time, often up to 90 days from the date the hearing was requested. Beneficiaries may also have the option to continue receiving the disputed service while the appeal is pending, known as “Aid Pending Appeal.”