Denied — Prior Authorization Denied: How to Appeal" class="auto-link">Prior Authorization Not Obtained — Emergency Exception and Appeals

Prior authorization (PA) is your insurer's way of reviewing certain treatments before you receive them. When that authorization isn't obtained — whether because of a provider oversight, an emergency, or a misunderstanding — the insurer can deny the claim after the fact. These denials can amount to thousands of dollars in unexpected bills.

But "prior authorization not obtained" is not always the end of the road. Here's how to fight back.

What Prior Authorization Actually Is

Prior authorization (also called pre-authorization, pre-certification, or pre-approval) is a requirement by some insurers that certain treatments, medications, or procedures be reviewed and approved before they're delivered. Common services requiring prior auth include:

• Elective surgeries
• MRI, CT, and PET scans
• Specialty medications and biologics
• Inpatient admissions
• Durable medical equipment
• Physical and occupational therapy (beyond initial visits)

When authorization isn't obtained, insurers commonly deny the claim — even if the service was medically necessary and covered under the plan.

The Emergency Exception: A Critical Protection

The most important protection to know: prior authorization cannot be required for emergency medical care. Under the ACA and most state laws, health plans must cover emergency services regardless of whether prior authorization was obtained. If your care was provided in a genuine emergency, the absence of a PA is not a valid denial reason.

"Emergency" is defined broadly. Under federal standards, an emergency exists when a prudent layperson — not a physician — would reasonably believe that the absence of immediate medical attention could result in serious harm. You do not need to prove the condition was ultimately life-threatening; you need to show it presented that way.

If your denial involves emergency care and the insurer is citing lack of prior authorization, your appeal should lead with this emergency exception argument.

The Continuity of Care Exception

If you were already in the middle of a course of treatment when a new authorization requirement was imposed — for example, if your plan changed mid-year and the new plan requires authorization for ongoing physical therapy — you may have a continuity of care right. Many states require plans to allow patients to complete ongoing treatment without interruption even if new PA requirements apply.

Step 1: Determine Who Was Responsible for Obtaining the Authorization

The first question is: whose job was it to obtain the prior authorization?

• Provider's responsibility: For most in-network care, the provider is responsible for obtaining prior authorization. If they failed to do so, the denial may be their error, not yours. Contact the billing department and ask whether they obtained PA and whether they'll assist with the appeal.

• Your responsibility: For some plans and some services (particularly out-of-network), the patient bears responsibility for obtaining authorization. Check your plan documents.

If the provider was responsible and failed to get authorization, they may be required to write off the balance — check your state's surprise billing and provider obligation laws.

Step 2: File an Expedited Appeal for Urgent Situations

If you need ongoing treatment and are being denied because prior auth wasn't obtained for previous services, file an expedited appeal immediately. Most plans must respond to expedited appeals within 72 hours. Do not wait for a standard 30-day internal review if your health situation is time-sensitive.

Step 3: Build Your Internal Appeal

Your appeal should address:

• Medical necessity: Even without authorization, the treatment was medically necessary and covered under your plan. Include your physician's letter of medical necessity.
• Emergency exception: If applicable, argue that the treatment met the emergency standard and authorization could not be obtained in advance.
• Provider error: If the provider failed to obtain authorization, document this and argue the member should not be penalized for a provider administrative failure.
• Good faith effort: If you or your provider attempted to obtain authorization and were unable to do so (e.g., the insurer's phone line was unavailable, you were hospitalized), document those attempts.

Step 4: Request a Retroactive Authorization

Ask your insurer directly whether they will grant retroactive authorization for the service. If the treatment was medically necessary and would have been approved had authorization been sought in advance, many insurers will approve it retroactively — particularly if your physician provides strong clinical support.

Step 5: External Independent Review: Complete Guide" class="auto-link">External Review and Regulatory Complaints

If the internal appeal fails, escalate to external review. External reviewers evaluate whether the denial was clinically appropriate, not just procedurally correct. A reviewer who finds the treatment was medically necessary can override the insurer's procedural denial.

For persistent failures, file a complaint with your state insurance commissioner. Many states have specific regulations about prior authorization fairness and insurer response times.

Fight Back With ClaimBack

Authorization denials are among the most appealed — and most successfully reversed — in the insurance system. ClaimBack helps you construct an appeal that hits the right arguments for your specific situation.

Start your appeal at ClaimBack and challenge the prior authorization denial.

Related Reading

• What Is Medical Necessity — And Why It Matters for Appeals
• How to Write an Insurance Appeal Letter
• Common Reasons Insurance Claims Are Denied