Prior Authorization Help
Prior authorization denials delay critical treatment. But 49-66% of appeals succeed. New CMS rules and state PA reform laws give you stronger rights than ever to fight back.
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Prior authorization (also called "pre-authorization" or "pre-cert") is a requirement by your health insurer that your doctor get approval before performing certain treatments, procedures, or prescribing certain medications. It was originally designed as a cost-control mechanism, but it has become one of the biggest barriers to timely medical care in the United States.
Common reasons for PA denials include: the insurer claims the treatment is not medically necessary, your condition does not meet their step therapy requirements (requiring you to try cheaper options first), the insurer wants additional clinical documentation, the request was submitted incorrectly or with missing information, or your specific plan excludes the service.
According to a 2022 American Medical Association survey, 94% of physicians report that prior authorization causes delays in care, 33% report PA has led to a serious adverse event for a patient, and 24% report PA has led to a patient's hospitalization.
Sources: AMA Prior Authorization Physician Survey 2022, CMS data, state insurance department reports
Upload the prior authorization denial notice. Our AI extracts the denial reason, clinical criteria cited, service requested, diagnosis codes, and your appeal deadline. No forms to fill out.
AppealArmor identifies whether the CMS PA Final Rule applies, searches for your state's PA reform laws, finds CMS coverage determinations and clinical guidelines supporting the requested service, and builds your legal argument using applicable federal and state law.
Your packet includes a detailed appeal letter citing clinical evidence and legal authorities, a state insurance commissioner complaint for regulatory pressure, and mailing instructions with strategic CC recipients. If your case is urgent, we include expedited appeal language.
Requires Medicare Advantage and Medicaid managed care plans to respond to standard PA requests within 7 days and urgent requests within 72 hours. Plans must provide specific denial reasons and cite the clinical criteria used. Applies to MA, Medicaid MCO, CHIP, and Marketplace plans.
Over 30 states have enacted prior authorization reform laws since 2020. Common provisions include gold-carding (exempting high-approval physicians from PA), continuity of care protections during plan changes, real-time PA decision requirements, and penalties for delayed PA responses. AppealArmor identifies which state laws apply to your situation.
The Affordable Care Act guarantees your right to appeal any PA denial through internal review and, if unsuccessful, through external independent review. Expedited appeals must be available for urgent situations where delay could cause serious harm.
Yes. Every health plan is legally required to offer an appeal process for PA denials. Under the ACA, you have the right to internal appeal and external independent review. The CMS Final Rule adds new requirements for Medicare Advantage and Medicaid plans. You typically have 180 days to file, though you should act quickly to avoid treatment delays.
Most commercial plans give you 180 days from the denial date. ERISA plans require at least 180 days. Medicare Advantage allows 60 days for standard reconsiderations. For urgent situations, request an expedited appeal immediately -- insurers must decide within 72 hours (24 hours for MA urgent cases). Check your denial letter for the specific deadline.
You can still appeal for retroactive authorization. This is especially strong if the service was an emergency (which cannot legally require PA), if the PA requirement was not clearly communicated, or if the service was medically necessary and would have been approved. Emergency services are protected under the ACA and the No Surprises Act regardless of PA status.
Finalized in January 2024, CMS-0057-F requires faster PA decisions (7 days standard, 72 hours urgent), specific denial reasons with clinical criteria, and public reporting of PA metrics. It applies to Medicare Advantage, Medicaid managed care, CHIP, and Marketplace plans. Many states have passed their own reforms with even stronger protections for commercial insurance.
Request an expedited appeal if delay could harm your health. Have your physician certify medical urgency. File a simultaneous complaint with your state insurance commissioner. Ask your doctor to request a peer-to-peer review with the insurer's medical director -- this often resolves denials within 24-48 hours without a formal appeal.
Upload your prior authorization denial and get a complete appeal packet with legal citations, clinical evidence, and regulatory complaints. Free, fast, and built to win.
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