Prior Authorization Deadline: 7 or 15?

You asked your insurer to approve a scan, and it said no. Or it said nothing at all, which is the same answer on a slower clock. Pushing back works only if you know which prior authorization deadline you are holding the insurer to. Most people guess seven days, the number in the headlines. For many readers the real figure is fifteen.

How Long Does Your Insurer Really Have to Respond?

Medicare Advantage plans and state Medicaid and CHIP programs must decide a standard request within seven calendar days and an urgent one within 72 hours, while an employer plan can take fifteen days for the same standard request.

The seven-day figure comes from the CMS fact sheet for rule CMS-0057-F, which binds Medicare Advantage and state Medicaid and CHIP programs and carves federal exchange insurers out of the timeframes. Compliance began on 1 January 2026 for Medicare Advantage and state fee-for-service programs. If your cover comes through an employer, this clock is not yours. Scope decides everything here, as it does for the right to repair laws in the US.

Employer plans answer to a different document, the Labor Department's claims rule at 29 CFR 2560.503-1. It gives a plan 15 days on a pre-service claim, which is my reading of a prior authorization request, and allows one 15-day extension if the plan tells you before the first period ends. That is about twice the Medicare Advantage wait, and more than four times with the extension. For India, see rejected health claims and the clause rule.

Conventional advice says to phone every day. I would write once, quote your calculated date and ask for the reason, because a dated letter leaves a record. Four numbers show what pushing back is worth. Three come from KFF's January 2026 analysis of Medicare Advantage requests in 2024, two years before these clocks began. The fourth is my own sum from the Labor Department text.

The extension is not automatic. The text allows it only for matters beyond the plan's control, and only if the plan tells you before the first period ends, so ask the plan in writing whether you were sent that notice.

Which Prior Authorization Deadline Applies to You?

Find the plan on your insurance card in the table: Medicare Advantage and Medicaid or CHIP follow the seven-day clock, employer plans follow fifteen days, and federal exchange plans sit outside the CMS decision timeframe.

Worked example: assume a standard request, not urgent, that your doctor's office submits on Tuesday 3 November 2026, with no missing paperwork. Seven calendar days puts the Medicare or Medicaid answer at Tuesday 10 November. Fifteen puts the employer plan at Wednesday 18 November, or Thursday 3 December if it uses its one extension. On these assumptions the gap is eight days, or 23 with the extension. Do the same sum with your own submission date: it takes under a minute, and that date is the one for your letter.

The employer row is the surprise, and the exchange row needs a second look, since the fact sheet only says what the CMS clock leaves out. Guessing the clock does not work, or not for long. A date, a letter and a reason do. My view: fifteen days is too slow for a scan your doctor wants soon, so ask the office to mark it urgent when delay could harm you.

Prior Authorization Denied: What Does the Notice Owe You?

A denial must state a specific reason: the CMS rule requires one from 2026 for covered plans, except for drugs, and the Labor Department rule makes an employer plan name its reasons and the plan provisions it relied on.

If the refusal is for a medication, the CMS reason duty does not reach it, so use the plan's own appeals process in your plan documents. The Federal Register notice frames the denial notice as one sent to your provider, so ask the doctor's office for a copy.

KFF reports that only 11.5% of Medicare Advantage denials were appealed. With the overturn rate above, that is my own sum: roughly nine of every 100 denials reversed in whole or part, and close to 89 never challenged. Averages hide the insurer, since KFF put UnitedHealth Group at the top of the denial range and Elevance Health at the bottom, and none of it speaks directly to employer plans. The same logic runs through cancelling a subscription after the FTC rule was vacated.

Public data cannot say which treatments are refused most, because CMS does not collect denials by service type. My view is that posted turnaround figures will matter more than the headline clock: covered plans must post approval and denial rates and median response times on their own websites, the first set due by 31 March 2026.

• If the plan asks for missing information, you get at least 45 days to supply it, so answer fast.
• The electronic approval API generally starts on 1 January 2027, so 2026 requests still wait on the deadline.

Decide today which clock is yours, add its days to the date the office submitted the request, and write that date on a calendar. If it passes without an answer, or a denial arrives, send one dated letter asking for the reason, then file the appeal. This holds only for plans the rule covers: with an exchange plan or a drug request, read your plan documents and confirm coverage on the CMS fact sheet.