My plan denied it because I didn't get prior approval. What can I do?

Health insuranceDeniedChecked Nov 6, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: GovInfo · 45 CFR § 147.138 «Coverage of emergency services» · paragraph (b)(2) View original ↗

In short

Emergencies never need prior approval.
For a drug, ask for an exception. It is decided in 72 hours, or 24 if urgent.
For other care, ask for the reason in writing and appeal within 180 days.

What this means

If your plan covers emergency room services, federal rules say it must cover emergency services without prior authorization, even out of network [1]. For a drug your plan does not cover, a health plan must have a process to ask for an exception. It must decide a standard request within 72 hours [2].

It must decide an expedited request within 24 hours when exigent circumstances exist. That means a health condition that may seriously jeopardize life or health, or a current course of treatment using a non-formulary drug [2]. For other care, the denial notice must refer to the plan provisions it used [3]. An employer group plan must give you at least 180 days after you receive the notice to appeal [4].

Your next step

For a drug the plan does not cover, ask for an exception; a standard request must be decided within 72 hours, and an expedited one within 24 hours when exigent circumstances exist [2]. For other care, read the plan provisions named in the notice [3]. An employer group plan must give you at least 180 days after you receive the notice to appeal [4].

Check it yourself

Open the first source above and read the part quoted. Your own policy papers hold details these sources do not give: "Don't know yet" for your case.

Where this comes from (8)

[1] GovInfo · 45 CFR § 147.138 «Coverage of emergency services» · paragraph (b)(2) · checked 2026-11-06
must provide coverage for emergency services in the following manner— ( i ) Without the need for any prior authorization determination, even if the emergency services are provided on an out-of-network basis
[2] GovInfo · 45 CFR § 156.122 «Prescription drug benefits: exceptions» · paragraph (c)(1)–(2) · checked 2026-11-06
A health plan must make its determination on a standard exception and notify the enrollee or the enrollee's designee and the prescribing physician (or other prescriber, as appropriate) of its coverage determination no later than 72 hours following receipt of the request … Exigent circumstances exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee's life, health, or abi…
[3] GovInfo · 29 CFR § 2560.503-1 «Claims procedure: notice of an adverse benefit determination» · paragraph (g)(1) · checked 2026-11-06
The specific reason or reasons for the adverse determination; ( ii ) Reference to the specific plan provisions on which the determination is based
[4] GovInfo · 29 CFR § 2560.503-1 «Claims procedure: appeal time» · paragraph (h)(3)(i) · checked 2026-11-06
Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination
[5] GovInfo · 29 CFR § 2560.503-1 «Claims procedure: appeal rights» · paragraph (h)(2)(iii) · checked 2026-11-06
Provide that a claimant shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits
[6] GovInfo · 29 CFR § 2560.503-1 «Time for the decision on review» · paragraph (i)(2)(i)–(iii) · checked 2026-11-06
In the case of a claim involving urgent care, the plan administrator shall notify the claimant, in accordance with paragraph (j) of this section, of the plan's benefit determination on review as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claimant's request for review of an adverse benefit determination by the plan … In the case of a pre-service claim…
[7] GovInfo · 45 CFR § 147.136 «External review: time frames» · external review process · checked 2026-11-06
at least four months after the receipt of a notice of an adverse benefit determination or final internal adverse benefit determination for a request for an external review to be filed … within no more than 45 days after the receipt of the request for external review by the IRO … As expeditiously as possible but within no more than 72 hours after the receipt of the request for expedited external review by the IRO
[8] HealthCare.gov · checked 2026-11-06
If your health insurance company is using the HHS-Administered Federal External Review Process, there's no charge. If your issuer has contracted with an independent review organization, or is using a state external review process, you may be charged. If so, the charge can't be more than $25 per external review … Call toll free: 1-888-866-6205 to request an external review request form

How we found this

We matched your question to 8 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.

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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