Appeal a Prior Authorization Denial

When your health insurance denies prior authorization for a service, treatment, or medication, you have the right to challenge that decision. The appeals process has clear steps and deadlines—here's how it works.

Step 1: Internal Appeals (Required First)

First-Level Appeal

What happens: Medical professionals at your insurance company (different from those who made the original prior authorization denial) review your case.

Your deadline: 180 days from the prior authorization denial date to submit your appeal

Insurance company's deadline to respond:

Urgent care: 72 hours
Future care (pre-service): 30 days
Past care (post-service): 60 days

What to include in your appeal:

  • Written appeal letter stating you're appealing the prior authorization denial
  • Your name, policy number, and prior authorization request details
  • Medical records supporting why you need this service, treatment, or medication
  • Letter from your doctor explaining the medical necessity
  • Any research or guidelines supporting the treatment

Second-Level Appeal (Optional)

Many insurers offer a second internal review if your first prior authorization appeal is denied. This gives you another chance before going to external review.

Timeline: Usually 60 days from first appeal denial, with similar response times[No text in field]

Step 2: External Review (Independent Review)

If both internal prior authorization appeals fail, you can request an independent review by medical experts with no connection to your insurance company. External review is available for prior authorization denials based on:

  • Medical necessity

  • Experimental/investigational treatments

  • Appropriate healthcare setting or level of care
  • Certain coverage decisions
  • Emergency services


Connecticut's Process

Your deadline: 120 days after final internal appeal denial

Review timeline:

  • Standard cases: 45 days
  • Urgent cases: 72 hours

How it works:

  1. Complete the Request for External Review form from CT Insurance Department
  2. Submit the form with all supporting documents.
  3. Independent reviewer evaluates your case
  4. Final decision is binding—if you win, your insurer must approve the prior authorization and cover the service

Need Help?

Don't let prior authorization denials or delays prevent you from getting the care you need. The Office of the Healthcare Advocate is here to help you navigate these challenges and ensure timely access to necessary treatment. We also offer educational seminars for both patients and providers to help you better understand and manage the prior authorization process.

 

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