Timeframes for Submission & Response for Prior Authorization Requests

Providers should anticipate Prior Authorization needs well in advance when feasible. Be sure to submit all applicable clinical information supporting the reason for the request.

The timeframes listed below are subject to change.

Non-Urgent (Routine) Preservice Requests.

The most common request type. Non-urgent (routine) preservice requests must be completed prior to rendering the service under consideration, or reimbursement cannot be guaranteed.

Medicare: Up to 7 days
Medicaid: Up to 14 days
Commercial: Up to 45 days

Urgent (Expedited) Preservice Requests

As defined by CMS, failure to expedite the review would “seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function” ^1,2.

Up to 72 hours.

Concurrent Review Requests

Made when a service is actively being delivered, most commonly an ongoing facility or home-based service, and are always handled as urgent.

Medicare: Up to 7 days
Medicaid: Within 1 business day after receiving required information, no later than 14 days after request received
Commercial: Within 1 business day after receiving required information, no later than 15 days after request received

Post Service Requests

Occur after a service has been delivered.

Up to 30 days

¹ Part C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance (Released February 2019), CMS.

² Any Expedited request requires a licensed provider’s signature on the PA form attesting to the validity of this statement of urgency.

Note that decisions are made as expediently as possible. The process may be slower due to a lack of sufficient clinical information to effectively process the request, requests for non-Preferred Specialist providers, or requests for providers who are non-participating with the payor.