How fast a plan has to decide a prior-authorization request
Before a denial even happens, there's a rule about how fast the plan has to decide the initial prior-authorization request — a real, binding deadline that's shorter than it used to be.
Source: Federal Register 2024-00895 (CMS-0057-F).
For standard (non-urgent) prior-authorization requests, a Medicare Advantage plan must decide within 7 calendar days. For expedited (urgent) requests, the deadline is 72 hours.Federal Register
Starting in 2026, a plan denying a prior-authorization request must give a specific reason for the denial, not a generic boilerplate explanation.Federal Register
By 2027, plans must offer an electronic Prior Authorization API — intended to make the request-and-response process faster and more transparent, though this hasn't taken effect yet.
What this means for your appeal
This is a different clock from the reconsideration deadline — it governs the plan's FIRST decision, before there's anything to appeal at all. If a plan takes noticeably longer than 7 days (or 72 hours for an urgent request) to make its initial decision, that delay is itself worth flagging, separate from the substance of the denial.
Once the specific-reason requirement is in effect (2026), a denial that only says something like "not medically necessary" with no further explanation falls short of what the rule requires — that gap is itself worth raising in an appeal.
This rule doesn't change the reconsideration deadlines described elsewhere on this site (30/60 days, or 72 hours if expedited) — those apply to the SECOND decision, after you've appealed. This rule is about how fast the FIRST decision has to happen.
The rule applies broadly across the payers CMS regulates through this process — Medicare Advantage organizations, state Medicaid and CHIP fee-for-service and managed care programs, and Qualified Health Plan issuers on the federal exchanges — so the same 7-day/72-hour standard is meant to apply consistently across most of the coverage types CMS oversees, not just Medicare Advantage alone.
The specific-reason and API requirements are being phased in over several years rather than all at once, which is common for a rule this broad — check the current effective date for each piece before assuming a specific protection is already in force for your case.
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By CaseWhy Appeals editorial. See how this content is produced. Not legal advice. Not affiliated with or endorsed by Medicare, CMS, or any health plan. A product of CaseWhy LLC.
