How long can my health plan take to decide a prior authorization request?

Health insuranceDeniedChecked Nov 5, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-05 · Source: eCFR · 29 CFR 2560.503-1(f)(2)(iii)(A) (row er-pre) View original ↗

In short

A job plan has 15 days to decide a request before care.
If care is urgent, it has 72 hours.
Count from the day the plan got your request.

What this means

For a job-based (ERISA) group health plan, a pre-service claim (approval before care) must be decided no later than 15 days after the plan receives it. The plan may extend once by up to 15 days for matters beyond its control, if it tells you before the first 15 days end [1]. For urgent care, the decision is due as soon as possible and no later than 72 hours; if information is missing, the plan must tell you within 24 hours what it needs [2].

Under the ACA rules, for urgent care claims the attending provider determines urgency and the plan defers to that [3].

HealthCare.gov describes the same idea for marketplace plans: the insurer must tell you in writing within 15 days if you are seeking prior authorization, and within 72 hours for urgent care [4].

Your next step

+ deadline: count from the date the plan received the request: 15 days (job-based, one possible 15-day extension), 72 hours if urgent [1] [2].

Where this comes from (4)

[1] eCFR · 29 CFR 2560.503-1(f)(2)(iii)(A) (row er-pre) · checked 2026-11-05
not later than 15 days after receipt of the claim by the plan. This period may be extended one time by the plan for up to 15 days, provided that the plan administrator both determines that such an extension is necessary due to matters beyond the control of the plan and notifies the claimant, prior to the expiration of the initial 15-day period
[2] eCFR · 29 CFR 2560.503-1(f)(2)(i) (row er-urgent) · checked 2026-11-05
as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claim by the plan … not later than 24 hours after receipt of the claim by the plan, of the specific information necessary to complete the claim.
[3] eCFR · 45 CFR 147.136(b)(2)(ii)(B) (row aca-urgent) · checked 2026-11-05
a claim involving urgent care has the meaning given in 29 CFR 2560.503-1(m)(1), as determined by the attending provider, and the plan or issuer shall defer to such determination of the attending provider.
[4] HealthCare.gov · Internal appeals (row aca-hc-int) · checked 2026-11-05
Within 15 days if you're seeking prior authorization for a treatment Within 30 days for medical services already received Within 72 hours for urgent care cases

How we found this

We matched your question to 4 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-05.

What we don’t know yet

Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.

Every answer is checked against the official rule it quotes.

Information only — not legal advice. Your plan, insurer or agency decides.

This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.

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