Prior authorization (PA), also known as pre-authorization or pre-certification, is a requirement imposed by health insurance plans that mandates approval from the carrier before a patient receives certain medical services, procedures, or prescriptions. Insurers use this process to determine if the proposed care is medically necessary, effective, and cost-efficient. Failure to obtain PA typically results in a claim denial, meaning the patient may be responsible for the entire cost of the care. Checking the status of a request is necessary for navigating the healthcare system without financial risk.
Primary Methods for Tracking a Request
The most efficient way to track the status of a prior authorization request is often through the dedicated digital systems provided by the payer. Most major insurance companies offer secure online portals where patients can log in using their member ID and the specific PA request number. These portals provide real-time updates on the status, showing whether it is “pending,” “approved,” or “denied.”
The simplest initial approach is to contact the medical provider’s office, as their staff is typically responsible for initiating the PA submission. Provider offices use specialized electronic health record (EHR) systems or dedicated payer portals to track the request directly. By contacting the medical office’s billing or authorization department, you can leverage their direct access for a status update.
A third method involves direct contact with the insurance carrier, usually by calling a dedicated phone number. The correct number is often listed on your physical insurance card, sometimes specifically for “Prior Authorization” inquiries. When calling, be prepared to provide your member identification number and the date the request was submitted.
Regulatory Timelines for Status Updates
Understanding the mandated timeframes helps set realistic expectations for when a status update should be available. The time a payer has to review a request is governed by state and federal regulations, which distinguish between standard and urgent requests. For a standard, non-urgent request, health insurers are typically required to issue a decision within seven to fifteen calendar days, depending on the specific plan and jurisdiction.
Requests deemed urgent are subject to a much shorter timeline, as a delay in care could seriously jeopardize the patient’s health. For these expedited requests, the insurer must respond within 72 hours after receiving all necessary medical information. Federal rules often mandate a standard response time of seven calendar days for non-urgent requests and 72 hours for urgent ones.
If the insurer fails to respond within the mandated regulatory timeframe, the request may be considered “deemed approved” under certain state laws. These timeframes apply once the payer has received all the required documentation from the medical provider. If the expected period passes without a decision, you or your provider should contact the payer to inquire about the delay.
Interpreting Status Results and Follow-Up Actions
An “Approved” status means the insurer has agreed to cover the service. The next step is to ensure the provider’s office receives the authorization number from the payer. This unique authorization number must be attached to the claim when the service is rendered to ensure proper payment.
If the status remains “Pending” or “Under Review” past the mandated regulatory deadlines, immediate action is required to avoid further care delays. The patient or provider should contact the state’s department of insurance or the relevant federal regulatory body, such as the Centers for Medicare and Medicaid Services (CMS). This action can help prompt the payer to finalize the review process or enforce a “deemed approval.”
A “Denied” status requires prompt initiation of the appeal process, which formally challenges the insurer’s decision. The denial notice will outline the specific reason for rejection, often based on a lack of medical necessity or a preference for an alternative treatment. Patients have the right to an internal appeal, followed by an external review by an independent third party if the internal appeal is unsuccessful. Success often relies on the provider submitting additional medical evidence to support the original request.