What Happens If Prior Authorization Is Denied: Complete Action Guide

Understanding What a Prior Authorization Denial Really Means

When you receive a prior authorization denial, this is NOT a final decision. It's the insurance company's initial response saying they won't approve the treatment, test, or medication yet - but you have strong appeal rights.

Here's what's actually happening:

The insurance company is saying: "Based on the information we have now, we don't believe this service meets our coverage criteria."

What they're NOT saying: "You can never have this treatment" or "Your doctor is wrong."

The Reality of Prior Authorization Denials

Insurance companies deny approximately 6% of prior authorization requests initially. But here's the critical fact most practices don't know:

82% of denied prior authorizations are partially or fully overturned upon appeal (Medicare Advantage data, 2019-2023).

Let me repeat that: More than 8 out of 10 denials get reversed when appealed properly.

So why do insurance companies deny in the first place? Three reasons:

1. Incomplete documentation (not enough clinical evidence provided)
2. Medical necessity criteria not met (based on their rules, not medical judgment)
3. Utilization management (cost control - they hope you won't appeal)

What Happens Immediately After a Prior Authorization Denial

First 24-48 Hours: What You'll Receive

1. Denial Notification

   • Your doctor's office receives the denial (usually electronically)
   • You receive written notice within 24-48 hours
   • The notice must include: denial reason, your appeal rights, and deadline

2. Denial Reason Code

   • Look for the specific code (varies by insurer)
   • Common codes:
     • "Medical necessity not established" - Most common, most reversible
     • "Requires step therapy" - Must try cheaper alternatives first
     • "Out-of-network provider" - Provider not in plan network
     • "Missing information" - Easy fix, resubmit with complete docs

3. Your Doctor Is Notified

   • Pharmacy or facility cannot proceed without approval
   • Your doctor can immediately request peer-to-peer review
   • Treatment is paused (unless you pay out-of-pocket)

What This Means for Your Treatment

For Non-Urgent Care:

• Treatment is delayed until approval
• You can begin appeal process immediately
• Average appeal takes 15-30 days for decision

For Urgent Care:

• Request expedited appeal (72-hour decision required)
• Consider paying out-of-pocket and seeking reimbursement
• Your doctor can document medical urgency for faster review

Can You Still Get Treatment If Prior Authorization Is Denied?

Yes. You have four options:

Option 1: Appeal the Denial (Recommended - 82% Success Rate)

This is your strongest option. The appeal process adds medical evidence that wasn't in the initial request.

Who can appeal:

• You (the patient)
• Your doctor (on your behalf)
• Your authorized representative

Timeline to file:

• Most insurers: 180 days from denial date
• Medicare Advantage: 60 days from denial date
• State requirements may vary (check your denial letter)

Success rate: 82% of appeals partially or fully overturn the denial.

Option 2: Request Peer-to-Peer Review (Fastest)

A peer-to-peer (P2P) review is a phone conversation between your ordering physician and the insurance company's medical director.

How it works:

1. Your doctor requests P2P review (usually within 24-72 hours of denial)
2. Phone call scheduled (typically 5-10 minutes)
3. Your doctor explains clinical necessity directly
4. Medical director makes decision immediately or within 24 hours

Success rate: Studies show P2P reviews overturn more than 50% of denials, especially for imaging and specialty procedures.

The catch: The insurance "peer" often doesn't have appropriate specialty qualifications. Only 16% of doctors report the reviewer had appropriate credentials. But it's still worth trying.

Option 3: Pay Out-of-Pocket and Seek Reimbursement

If you cannot wait for appeal, you can pay the full cost and request reimbursement if your appeal succeeds.

Considerations:

• You'll pay the uninsured price (no negotiated insurance discount)
• Specialty medications can cost thousands per dose
• Keep all receipts and submit with appeal
• Reimbursement only if appeal succeeds

When this makes sense:

• Treatment cannot be delayed without harm
• Cost is manageable for your financial situation
• Strong likelihood of appeal success (your doctor is confident)

Option 4: Try Alternative Treatments

Your insurance may approve a different (usually cheaper) treatment first.

Common alternatives:

• Generic medication instead of brand-name
• Conservative treatment (physical therapy before surgery)
• Different diagnostic test (X-ray before MRI)
• In-network specialist instead of out-of-network

Ask your doctor: "What would you recommend if the insurance doesn't approve, and is there a covered alternative that would work?"

The Prior Authorization Appeal Process: Step-by-Step

For a comprehensive breakdown of the entire appeal process including templates and timelines, see our complete guide to prior authorization denial reasons and appeals.

Step 1: Request Detailed Denial Reason (Within 48 Hours)

Don't accept vague denial reasons like "not medically necessary."

Call your insurance company and demand:

• Which medical policy was applied
• Which specific criteria were not met
• What additional documentation would support approval

Script to use:

"I'm calling regarding denied prior authorization [number]. The denial states 'medical
necessity not established' but doesn't specify which criteria were not met. I need:
1. The medical policy number applied to this denial
2. The specific coverage criteria that weren't satisfied
3. What additional documentation the medical director needs

Federal regulations require you provide this information."

They must tell you. It's required under ACA and ERISA regulations.

Step 2: Gather Medical Evidence (Week 1)

Work with your doctor's office to compile:

Required Documentation:

• ☐ Complete medical records (minimum 6 months)
• ☐ Physician letter of medical necessity
• ☐ Failed conservative treatment documentation
• ☐ Clinical practice guidelines supporting treatment
• ☐ Peer-reviewed studies (2-3 abstracts)
• ☐ Diagnostic test results
• ☐ Specialist consultation notes (if applicable)

Pro tip: Reference the insurance company's own medical policy. Copy their coverage criteria and explicitly address each one. It's difficult for reviewers to deny when you prove you meet THEIR OWN rules.

Step 3: Submit Your Appeal (Week 1-2)

Filing Methods (by insurer):

What to submit:

1. Appeal request form (provided by insurer)
2. Appeal letter from physician
3. All supporting medical documentation
4. Your personal statement (optional but powerful)

Deadline: Don't wait. File within 30 days for fastest processing, even though you have 60-180 days.

Step 4: Wait for Decision (15-30 Days)

What happens during review:

Days 1-5:

• Insurance acknowledges receipt
• Assigns case to medical reviewer
• May request additional information (you have 10 days to respond)

Days 5-15:

• Medical director reviews documentation
• May offer peer-to-peer review (ACCEPT THIS - physicians speaking directly often resolves denials)
• Reviews against medical policy criteria

Days 15-30:

• Final decision issued in writing
• Approved: Service is authorized, proceed with treatment
• Denied: Move to external review (independent third party)

Step 5: If Denied, Request External Review (Free)

You have the right to independent external review by medical experts not affiliated with your insurance company.

Who reviews your case: Independent board-certified physicians in your condition's specialty

Timeline: 60 days for decision (expedited: 72 hours for urgent cases)

Success rate: Approximately 40% of external reviews overturn insurance denials

Cost: Free (required by federal law)

Prior Authorization Appeal Timeline by Insurance Company

Here's exactly how long you have to appeal and how long the insurance company has to decide, by major insurer:

What If You Need Treatment Urgently?

If delaying treatment could seriously harm your health, you can request an expedited appeal.

When You Qualify for Expedited Review

Your situation qualifies if:

• Standard timeline could "seriously jeopardize your life or ability to regain maximum function"
• You're experiencing severe pain that cannot be adequately managed
• You need ongoing treatment that requires immediate decision

Expedited Appeal Timeline

• 72 hours for decision (most insurers)
• 4 business days maximum (federal requirement)
• Can request external review simultaneously with internal appeal if urgent

How to Request Expedited Review

Include this language in your appeal:

"I am requesting EXPEDITED review under [Insurance Company]'s urgent appeal
procedures. Delay in receiving [treatment] will seriously jeopardize my health
because [specific medical harm]. My physician's statement documenting urgent
medical need is attached."

Your doctor must provide a statement explaining:

• Why the treatment is urgent
• What harm will occur from delay
• Timeline for when treatment is needed

Understanding the Cost Implications

If Prior Authorization Is Approved on Appeal

Best case scenario:

• Treatment proceeds as planned
• You pay only your copay/coinsurance
• Insurance covers the negotiated rate
• No out-of-pocket surprise

If Prior Authorization Remains Denied

You have three options:

1. Pay full cost out-of-pocket

   • No insurance discount applies
   • Specialty drugs: $5,000-$50,000+ per dose
   • Procedures: $10,000-$100,000+ without insurance
   • You own the financial responsibility 100%

2. Try alternative covered treatment

   • Often a less expensive option
   • May be less effective (that's why your doctor didn't recommend it first)
   • Insurance will cover with normal cost-sharing

3. Forego treatment

   • 79% of doctors report patients abandoning prescribed treatment due to prior auth denial
   • Results in delayed care, worsening conditions, higher costs later

The Hidden Cost of Delays

According to American Medical Association surveys:

• 93% of physicians report prior authorization delays care
• 34% of physicians report prior authorization has led to serious adverse events
• 18% of physicians report prior authorization has led to hospitalizations

Every day matters. File your appeal immediately.

Why Was My Prior Authorization Denied? (Top 9 Reasons)

If you're asking "Why was my prior authorization denied?" - you're not alone. Prior authorizations are denied for 9 primary reasons, and understanding which applies to your situation helps you fix it faster.

Top 9 Prior Authorization Denial Reasons

1. Medical Necessity Not Established (47% of denials)

• Insurance doesn't believe your condition is severe enough based on documentation provided
• How to fix: Provide objective severity measurements, functional impact, and clinical guideline citations

2. Lack of Information (23% of denials)

• Incomplete documentation, missing forms, illegible records
• How to fix: Resubmit with complete medical records matching the procedure code
• Easiest to overturn - most get approved with complete info

3. Non-Covered Benefit (17% of denials)

• Service not covered under your plan or deemed experimental
• How to fix: Review plan documents, provide FDA approval and peer-reviewed studies for experimental claims

4. Step Therapy Required (10% of denials)

• Must try cheaper alternatives first (generic before brand-name)
• How to fix: Document all cheaper alternatives already tried and failed with specific dates

5. Out-of-Network Provider (3% of denials)

• Provider isn't in your insurance network
• How to fix: Prove no in-network provider available with required expertise

6. Coding Errors

• ICD-10 or CPT codes incorrect, outdated, or don't align with service description
• How to fix: Verify codes are current and match treatment exactly

7. Expired Authorization or Timing Issues

• Prior auth expired before service was performed
• How to fix: Request timely extension or submit new prior auth immediately

8. Duplicate Requests

• Multiple prior auth requests for same service without addressing previous denial
• How to fix: Reference previous denial and provide NEW documentation addressing denial reason

9. Procedural Non-Compliance

• Failed to obtain prior auth before non-emergency service
• How to fix: Submit retroactive authorization request with documentation of emergency or administrative error

Why Do Prior Authorizations Get Denied? (Insurance Company Perspective)

Understanding insurance company motivations helps you appeal effectively:

Cost Control Strategy:

• Denying first, approving on appeal reduces overall spending
• Only 11% of denials get appealed (they're counting on you giving up)
• Average savings per unchallenged denial: $5,000-$15,000

Utilization Management:

• Forces providers to submit thorough evidence (weeds out unnecessary requests)
• Encourages trying cheaper alternatives first
• Delays expensive treatments hoping condition improves without intervention

Incomplete Documentation:

• Many initial requests genuinely lack medical justification
• Denials force providers to provide comprehensive evidence
• This is legitimate (though frustrating) quality control

The 82% Overturn Rate Proves: Most denials are administrative hurdles, not legitimate medical necessity concerns.

What Happens If Prior Authorization Is Denied: Your 4-Step Action Plan

If your prior authorization was denied, here's exactly what to do next:

Immediate Actions (First 48 Hours):

1. Request detailed denial reason

   • Call insurance: demand specific criteria not met
   • Get medical policy number applied to denial
   • Ask what documentation would support approval

2. Have your doctor request peer-to-peer review

   • Schedule within 24-72 hours of denial
   • 50%+ overturn rate in phone conversation
   • Fastest resolution option

Week 1 Actions:

3. Gather comprehensive documentation

   • Complete medical records (6+ months)
   • Physician letter of medical necessity
   • Clinical guidelines supporting treatment
   • Failed conservative treatment proof

4. Submit formal appeal

   • File within 30 days (even though you have 60-180)
   • Include all documentation
   • Reference insurance company's own medical policies

Expected Timeline:

• Appeal decision: 15-30 days standard, 72 hours expedited
• Success rate: 82% overturned with proper documentation
• If denied again: Move to external independent review (40% success rate)

What To Do If Prior Authorization Is Denied: Treatment Options

Can I still get treatment? Yes. You have four options:

Option 1: Appeal (Recommended - 82% Success)

• File appeal with medical evidence
• Wait 15-30 days for decision (72 hours if expedited)
• Treatment covered if approved

Option 2: Pay Out-of-Pocket and Seek Reimbursement

• Pay full uninsured price (no insurance discount)
• Keep all receipts
• Request reimbursement if appeal succeeds
• Risk: No reimbursement if appeal fails

Option 3: Try Alternative Covered Treatment

• Often cheaper option (why insurance prefers it)
• May be less effective
• Insurance covers with normal cost-sharing

Option 4: Request Peer-to-Peer Review First

• Doctor speaks to insurance medical director
• 5-10 minute phone call
• 50%+ overturn rate
• Decision within 24 hours

Understanding Prior Authorization Denials: Common Questions

Can a Prior Authorization Be Denied?

Yes. 6% of prior authorization requests are initially denied, with medical necessity disputes being the most common reason. However, 82% of denied prior authorizations are overturned on appeal when proper documentation is provided.

Insurance companies can deny prior authorizations for legitimate reasons (service not covered, experimental treatment) or administrative reasons (incomplete documentation, step therapy required). Every denial includes your appeal rights and deadlines.

What Is "Authorization Denial" vs "Prior Authorization Denial"?

Authorization denial is broader - includes:

• Prior authorization denial: Request denied before service
• Concurrent review denial: Ongoing treatment terminated
• Retrospective denial: Claim denied after service provided

All types of authorization denials can be appealed using similar processes, though timelines differ.

Why Prior Authorizations Get Denied (And How to Fix It)

Now let's dive deeper into each denial reason with specific solutions:

1. "Medical Necessity Not Established" (47% of Denials)

What this really means: The insurance company doesn't believe your condition is severe enough to warrant this treatment based on the documentation provided.

How to fix it:

• Provide objective severity measurements (pain scale 8/10, functional limitation scores)
• Document impact on daily living (can't work, can't dress yourself, etc.)
• Include progression timeline showing worsening despite current treatment
• Cite clinical practice guidelines showing you meet criteria

2. "Lack of Information" (23% of Denials)

What this really means: Your doctor's office submitted an incomplete prior auth request (missing documentation, wrong forms, illegible records).

How to fix it:

• Resubmit with complete medical records
• Ensure documentation matches the procedure code (CPT code)
• Include all required forms
• Verify information is legible (not handwritten notes)

This is the easiest denial to overturn. Most get approved on resubmission with complete information.

3. "Non-Covered Benefit" (17% of Denials)

What this really means: The service isn't covered under your specific insurance plan, OR the insurance considers it "experimental/investigational."

How to fix it:

• Review your plan benefits document carefully (they may be wrong)
• If experimental: provide FDA approval, peer-reviewed studies showing efficacy, evidence of widespread clinical acceptance
• If truly not covered: appeal based on medical necessity exception or continuity of care

4. "Step Therapy Required" (10% of Denials)

What this really means: Insurance requires you try cheaper alternatives first (like generic drugs before brand-name).

How to fix it:

• Document all cheaper alternatives already tried and failed
• Provide specific outcomes (dates, duration, why each failed)
• Show medical contraindications to alternatives (allergies, drug interactions)
• Include pharmacy records proving prior attempts

5. "Out-of-Network Provider" (3% of Denials)

What this really means: The provider submitting the prior auth isn't in your insurance network.

How to fix it:

• Prove no in-network provider available with required expertise
• Document emergency situation where you couldn't choose in-network
• Request single-case agreement for out-of-network provider at in-network rates

Insurance Company-Specific Prior Authorization Denial Strategies

Each major insurer has different policies and approval rates. Here's what you need to know:

Aetna Prior Authorization Denials

Denial rate: ~6% initially denied Success rate on appeal: 75-85% overturned Key to success: Reference Aetna Clinical Policy Bulletins (CPBs) by number in your appeal

Aetna-specific tip: Aetna offers "pre-determination" where you can check if a service will be covered BEFORE submitting formal prior auth. Use this to avoid denials.

Blue Cross Blue Shield Prior Authorization Denials

Special challenge: BCBS is 34 independent companies with different policies Denial rate: Varies by state (6-8% average) Key to success: Identify which BCBS company (Anthem, Premera, Horizon, etc.) and reference THEIR specific medical policy

BCBS-specific tip: Check which BCBS company you have (on your ID card). Using the wrong company's policy is an automatic denial.

UnitedHealthcare Prior Authorization Denials

Denial rate: ~7% initially Fast appeals: UHC decides appeals in 7 days (fastest among major insurers) Key to success: UHC heavily uses InterQual criteria - cite these in your appeal

UHC-specific tip: UHC offers "Gold Card" program exempting high-performing doctors from prior auth. Ask your doctor if they qualify.

Cigna Prior Authorization Denials

Denial rate: ~6% initially Success rate on appeal: 70-80% Key to success: Cigna uses eviCore for radiology prior auths - different criteria than Cigna medical policies

Cigna-specific tip: Request peer-to-peer immediately for denials. Cigna's P2P process often resolves issues same-day.

Medicare Advantage Prior Authorization Denials

Denial rate: Higher than commercial (8-10%) BUT success rate on appeal: 82% (higher than commercial!) Key to success: Medicare Advantage plans must follow CMS Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs) - cite these, not just plan policy

Medicare-specific tip: If denied twice, you can escalate to CMS Independent Review Entity (IRE), then to Administrative Law Judge (ALJ). You have 5 levels of appeal in Medicare.

How to Write a Winning Prior Authorization Appeal Letter

Your appeal letter is the single most important document. Here's the structure that achieves 82% success:

Opening Paragraph: State the Facts

I am writing to appeal the denial of prior authorization request [number] for
[patient name], DOB [date], Member ID [number]. [Insurance Company] denied
prior authorization for [specific service/medication] on [date] for reason
"[exact denial reason]". I respectfully disagree with this determination and
provide the following clinical evidence demonstrating medical necessity.

Section 1: Patient Clinical Presentation

Document objective severity:

• Specific diagnosis with ICD-10 codes
• Severity measurements (pain scores, functional assessments, lab values)
• Impact on daily living with specific examples
• Progression timeline showing worsening

Section 2: Conservative Treatments Have Failed

Insurance companies want to see you tried cheaper options first:

• List each prior treatment with dates and duration
• Document specific outcomes (X-ray showed no improvement, pain decreased from 8/10 to only 7/10)
• Explain why each failed or was inadequate
• Include pharmacy records, prior imaging reports, therapy discharge notes

Section 3: Meets Insurance Company's Criteria

This is critical - use their own rules:

• Reference the specific medical policy by number
• Copy their coverage criteria verbatim
• Address each criterion explicitly
• Prove patient meets ALL requirements

Section 4: Evidence-Based Medicine Supports This

• Cite clinical practice guidelines from medical specialty societies
• Include 2-3 peer-reviewed study abstracts
• Show this is standard of care for patient's condition
• Quote expert consensus statements

Section 5: Request for Approval

Based on the above documentation, [patient name] meets [Insurance Company]'s
medical policy criteria for [service]. This treatment is medically necessary,
supported by clinical evidence, and represents the appropriate standard of care.
I request approval of this prior authorization and am available for peer-to-peer
review at your convenience.

Automate Your Prior Authorization Appeals with Muni

Manual prior authorization appeals take 45 minutes of staff time per denial. That's time your office doesn't have when managing a full patient load.

Muni Appeals automates the entire process while improving your success rate:

What Muni Does:

1. Analyzes your denial reason and identifies the specific insurance medical policy
2. Searches relevant clinical guidelines, CPT codes, ICD-10 codes, and peer-reviewed evidence
3. Generates a comprehensive appeal letter addressing insurance company's specific criteria
4. Tracks submission and follows up on appeal status
5. Reports success/failure and revenue recovery

Results:

• ⏱️ 5 minutes per appeal (vs. 45 minutes manual)
• 📈 89% success rate (vs. 75% industry average)
• 💰 $47,000+ average annual revenue recovery per practice
• 🤖 Handles all major insurers: Aetna, BCBS, UHC, Cigna, Humana, Medicare Advantage

→ Try 3 Free Prior Authorization Appeals (No Credit Card Required)

Frequently Asked Questions

Can I get treatment while my prior authorization appeal is pending?

Yes, you have options: (1) Pay out-of-pocket and seek reimbursement if your appeal succeeds, (2) Request expedited appeal (72-hour decision) if treatment is medically urgent, (3) Try alternative covered treatments while appeal is pending, or (4) For life-threatening situations, proceed with treatment and file emergency appeal afterward. Many pharmacies will let you pay with a credit card and reimburse you if prior auth is approved within a week.

How long does a prior authorization appeal take?

Standard prior authorization appeals take 15-30 days for most insurance companies to decide. Expedited appeals for urgent medical situations must be decided within 72 hours (or 4 business days maximum). Medicare Advantage standard appeals take 30 days. If the insurance company misses their deadline, you can move directly to external independent review.

What percentage of prior authorization appeals are successful?

82% of prior authorization appeals are partially or fully overturned according to Medicare Advantage data from 2019-2023. However, only 11% of denials are actually appealed, despite this high success rate. Insurance companies are counting on you not appealing - don't let them win.

Who can help me appeal a prior authorization denial?

Your doctor's office can file the appeal on your behalf (most common), you can file the appeal yourself as the patient, or you can authorize a representative (family member, patient advocate) to appeal for you. Most successful appeals involve your physician because they provide the medical evidence and clinical justification. Muni Appeals automates this process for medical practices, reducing appeal time from 45 minutes to 5 minutes while improving success rates to 89%.

Will I have to pay out of pocket if prior authorization is denied?

If prior authorization is denied and you proceed with treatment anyway, yes - you'll pay the full uninsured price (no insurance discount). For specialty medications this can be $5,000-$50,000+ per dose. For procedures, $10,000-$100,000+ without insurance. However, if you appeal and win, you can often get reimbursed. Alternatively, wait for your appeal to be approved before getting treatment (15-30 days for standard appeals).

Can my doctor do a peer-to-peer review with the insurance company?

Yes. A peer-to-peer (P2P) review is a phone call between your ordering physician and the insurance company's medical director. Your doctor can request this immediately after a denial, usually scheduled within 24-72 hours. The call typically lasts 5-10 minutes, and more than 50% of denials are overturned during P2P review. Request this option - it's the fastest way to get a denial reversed.

What if my prior authorization appeal is denied a second time?

You can request external independent review by medical experts not affiliated with your insurance company. This is required by federal law at no cost to you. An independent board-certified physician in your condition's specialty reviews your case and makes a binding decision. External reviews overturn about 40% of insurance denials. For Medicare Advantage, you have additional appeal levels: Medicare reconsideration, ALJ hearing, Medicare Appeals Council, and federal court.

Do I need a lawyer to appeal a prior authorization denial?

No. The vast majority of prior authorization appeals are successfully handled by your doctor's office or by you directly, without legal representation. Focus on medical evidence, clinical guidelines, and meeting the insurance company's own coverage criteria. Lawyers are typically only needed if you're pursuing litigation after all appeal levels are exhausted (rare for medical necessity disputes). Muni Appeals provides automated letter generation and evidence compilation without legal fees.

What is the difference between internal and external prior authorization appeals?

An internal appeal is submitted directly to your insurance company, where their medical director reviews your case. You must complete internal appeals before external review (typically 30 days for decision). An external appeal (also called independent review) is reviewed by medical experts NOT employed by your insurance company. External review is free, binding on the insurer, and takes up to 60 days (or 72 hours if urgent). You must exhaust internal appeals first unless the insurer fails to follow proper procedures.

Why do insurance companies deny so many prior authorizations if 82% get overturned?

Insurance companies deny prior authorizations as a utilization management strategy to control costs. They know only 11% of denials are appealed, so denying first and approving on appeal reduces overall spending. Additionally, many initial requests lack complete documentation, so denials force providers to submit thorough evidence. The high overturn rate proves most denials are not legitimate medical necessity concerns but administrative hurdles designed to discourage treatment.

How much does it cost to appeal a prior authorization denial?

Appealing a prior authorization denial is free. Federal law prohibits insurance companies from charging fees for internal or external appeals. The only "cost" is time - manual appeals take approximately 45 minutes of staff time to compile documentation and write the appeal letter. Automated solutions like Muni Appeals reduce this to 5 minutes while improving success rates.

Can I appeal a prior authorization denial for out-of-network services?

Yes, you can appeal out-of-network prior authorization denials, but success depends on demonstrating: (1) no in-network provider is available with the required expertise or specialty, (2) you received emergency services where you couldn't choose an in-network provider, or (3) requesting a "single-case agreement" where the insurer agrees to cover the out-of-network provider at in-network rates. Include documentation proving these circumstances in your appeal.

Don't Let Insurance Companies Win By Delay

Here's the truth about prior authorization denials: Insurance companies are betting you won't appeal.

They know:

• 82% of appeals succeed
• Only 11% of denials are appealed
• Most patients and practices give up

Every denied prior authorization is a test of your persistence. Will you spend 45 minutes fighting for your patient's care, or will you move on to the next patient?

This is exactly why independent medical practices need automated appeals. You don't have time to fight every denial manually, but you can't afford to accept them either.

The solution: Automate your prior authorization appeals so you can fight every denial without adding staff time.

→ Start Your First 3 Prior Authorization Appeals Free

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This guide is updated for 2025 prior authorization and appeal procedures. Appeal requirements and timelines vary by insurance company, state, and plan type. Muni Appeals stays current with all insurance company policy changes and automates appeals for Aetna, Blue Cross Blue Shield, UnitedHealthcare, Cigna, Humana, and Medicare Advantage plans.