Prior Authorization Denied? What to Do Next

Mukesh MakwanaFounder & CEO · 8+ years hands-on in medical billing & RCM · Reviewed October 1, 2026

When a prior authorization is denied, do not reschedule the patient and move on. Read the denial reason, fix anything that was missing and resubmit, or ask for a peer-to-peer review with the plan's reviewer, and if that fails, file a formal appeal inside the plan's deadline. A denial caused by missing information can often be reversed once that information is in front of the reviewer.

What to do in the first 48 hours

Get the exact reason. Under the CMS Interoperability and Prior Authorization final rule, Medicare Advantage, Medicaid, CHIP and their managed care plans and exchange plans must give a specific reason for a prior authorization denial beginning in 2026. For other plans, call and ask which criterion was not met.
Check whether it was administrative. Wrong member ID, wrong code, missing form, request sent to the wrong plan or vendor. These are usually fixed by correcting and resubmitting, not by appealing.
Check the clinical criteria. Pull the plan's policy for the service and compare it line by line with what was sent.
Tell the provider and the patient what happened and what the next step is, so care is not silently delayed.
Write down the deadline for reconsideration or appeal the day the denial arrives.

Your options, from fastest to slowest

Option	When to use it
Corrected resubmission	The request was incomplete or had an administrative error.
Peer-to-peer review	The case turns on clinical judgment. The ordering clinician speaks with the plan's medical reviewer. Many plans offer it only for a short window after the denial.
Reconsideration or internal appeal	The plan stands by the denial. Send a written appeal with the policy criteria matched to the record.
External or independent review	Internal appeals are exhausted. Available for Medicare Advantage through the independent review entity, and for most non-grandfathered commercial plans under federal rules.

Deadlines and timeframes that apply

Medicare Advantage: a request for a standard reconsideration must be filed within 60 calendar days after receiving the written denial notice. A treating physician may request a standard reconsideration of a pre-service denial on the patient's behalf, after notifying the patient. If the plan upholds its denial in whole or part, it must send the case to the independent review entity contracted by CMS.
Urgent cases: for expedited requests, Medicare Advantage plans must decide as quickly as the patient's health requires and no later than 72 hours for items and services.
Employer plans covered by ERISA: claimants must be given at least 180 days to appeal an adverse benefit determination.
Non-grandfathered commercial plans: once internal appeals are exhausted, a denial based on medical necessity can generally go to independent external review.
Medicaid managed care and other plans: follow the plan's provider manual and your contract.

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Writing an appeal that gets approved

Open with the patient, the service, the date of the denial and the plan's stated reason.
Quote the plan's own criteria and show, point by point, where the record meets each one.
Attach the specific notes, test results, imaging and history of earlier treatments that prove it.
Add a short letter from the treating clinician explaining why the service is needed now.
If a less costly alternative was tried and failed, say so with dates.
Send it in the format the plan requires, and keep proof of when it was received.

Common reasons prior authorizations are denied

Clinical notes do not show the criteria the plan requires, such as duration of symptoms or failed earlier treatment.
The request was sent for the wrong code, units or site of service.
Step therapy or conservative treatment requirements were not documented.
The request went to the health plan when the plan uses a separate utilization management vendor.
The service was already provided before approval.

Why this is worth the effort

Prior authorization problems affect patients, not just revenue. In the AMA's 2025 survey of 1,000 practicing physicians, nearly four in five (79%) reported patients abandoning treatment because of authorization challenges. A denied request that is reversed quickly keeps the patient in care.

How Sterling Global Solution LLC handles denied authorizations

We read the plan's stated reason, fix and resubmit administrative errors the same day, prepare the clinical summary for a peer-to-peer review, and draft the written appeal with the plan's criteria matched to the record, inside the deadline. Then we track the outcome and make sure the approval number reaches the claim. Prevention is the bigger win: see our prior authorization services, and for authorizations that turn into claim denials, our denial management services.

Frequently asked questions

What should I do when a prior authorization is denied?

Get the exact reason, correct and resubmit if it was an administrative error, request a peer-to-peer review if it turns on clinical judgment, and file a written reconsideration or appeal inside the plan's deadline if the plan stands by the denial.

How long do I have to appeal a Medicare Advantage prior authorization denial?

A request for a standard reconsideration must be filed within 60 calendar days after receiving the written denial notice.

Can the doctor appeal a prior authorization denial for the patient?

For Medicare Advantage, a treating physician may request a standard reconsideration of a pre-service denial on the patient's behalf after notifying the patient. Commercial plans set their own rules for provider appeals.

What is a peer-to-peer review?

A conversation between the ordering clinician and the plan's medical reviewer about a denied request. It is often the fastest way to reverse a denial that turns on clinical judgment.

Do plans have to say why they denied a prior authorization?

Under the CMS Interoperability and Prior Authorization final rule, Medicare Advantage, Medicaid, CHIP and their managed care plans and exchange plans must give a specific reason for prior authorization denials beginning in 2026.

Sources

Centers for Medicare & Medicaid Services, CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheet: specific denial reasons from 2026.
Code of Federal Regulations, 42 CFR 422.582 (Medicare Advantage reconsideration requests), 42 CFR 422.572 (expedited determinations) and 42 CFR 422.590 (reconsideration timeframes and independent review).
Code of Federal Regulations, 29 CFR 2560.503-1 and 45 CFR 147.136: group health plan appeals and external review.
American Medical Association, 2025 AMA Prior Authorization Physician Survey, released May 13, 2026.

Plan rules and contracts vary. This is general billing information, not legal advice. How we verify this guidance.