Your care needs approval from your insurance first
This is called prior authorization. Our office asks your plan; your plan has a legal deadline to answer.
Track it and get call scripts
Who does what
- We send the request to your plan, with your records.
- Your plan decides. Don’t schedule or pay for the care until it’s approved, or you could be billed for it.
- You can track it: write the details below, and call your plan if you don’t hear back.
How long your plan has to decide
- Medicare Advantage, Medicaid and CHIP: 7 days (72 hours if urgent).
- Job-based and Marketplace (HealthCare.gov) plans: 15 days (72 hours if urgent).
- Medicaid and Medicare Advantage: a missed deadline counts as a denial you can appeal.
If it’s late or denied
- Call your plan (number on your card): ask if they have it, what’s missing, and when it’s due.
- If denied, ask us about a “peer-to-peer” review and a letter of medical necessity.
- Appeal deadlines: 60 days (Medicaid), 65 days (Medicare Advantage), 180 days (job-based and Marketplace).
Write it down
- Date we sent it
- (blank to fill in)
- Request or reference number
- (blank to fill in)
- Your plan’s phone (back of your card)
- (blank to fill in)
- Date the decision is due
- (blank to fill in)