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Free tool · Verified September 2026

Prior Authorization Deadlines: How Long Can the Payer Take?

There is no single prior authorization deadline that applies to every payer and every request. The timeframe depends on the payer or program, whether the request is standard or expedited, whether it concerns a drug or a medical item or service, and which federal or state rule applies. This page finds the rule that fits your situation, links to the regulation it comes from, and says what to do next.

  • 8 payer programsMedicare, Medicaid, CHIP, marketplace, commercial
  • Standard & expeditedBoth timeframes, with extensions
  • Every rule citedCFR and CMS sources on each answer
  • FreeNo login, runs in your browser

Federal rules were read directly on eCFR and in the CMS-0057-F final rule as published in the Federal Register. Every timeframe below is labelled by payer or program, by item or service versus drug, by standard versus expedited, and by its compliance date. Last verified September 22, 2026. General rule information, not legal advice or a coverage determination.

Prior Authorization Deadline Finder

Select the payer or program, what is being requested and the urgency. The finder returns the timeframe that applies, whether it is counted in calendar days, business days or hours, what extension is permitted, what is excluded, and the regulation behind it. Where no single federal deadline exists, it says so instead of offering a number.

Free tool

Which prior authorization rule applies?

Medicare Advantage, Original Medicare, Medicaid, CHIP, marketplace and commercial plans — items and services and drugs handled separately.

Expedited applies where the standard timeframe could seriously jeopardize the patient’s life, health or ability to regain maximum function.
Used only to show the resulting date.

How Long Does Prior Authorization Take?

Search results usually answer this with a range, such as “a few days to a few weeks”. That range is not wrong, but it is not usable: it mixes together payers that are bound by a federal deadline with payers that are not, and it ignores the difference between a drug and a medical service. Four questions decide the answer.

  1. Is this a drug or a medical item or service? The 2026 federal timeframes cover items and services and exclude drugs. Drug requests run on a different set of rules entirely.
  2. Which payer or program is reviewing it? Medicare Advantage, Medicaid, CHIP, a marketplace plan, a commercial plan and Original Medicare are governed by different rules. A Medicare Advantage plan is not Original Medicare, and that single confusion causes most wrong answers.
  3. Is the request standard or expedited? Expedited handling has its own, much shorter clock, and it has a clinical test attached to it.
  4. Is the payer one of the impacted payers under CMS-0057-F? That rule reaches Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans and CHIP managed care entities. It does not set timeframes for marketplace QHP issuers, and it does not reach commercial plans or Original Medicare.

Two more questions decide whether the federal answer is the final answer: is a state rule shorter, and does an extension apply. Both are covered below.

Federal Rules by Payer and Program

Each card states one rule, the payer or program it belongs to, what it excludes, and when it took effect. Nothing here is carried across from one programme to another.

Medicare Advantage — items and services

Federal · from Jan 1, 2026

Standard: no later than 7 calendar days after receiving the request, for an item or service subject to the prior authorization rules in 42 CFR 422.122, and as expeditiously as the enrollee’s health condition requires. For items and services not subject to those rules the timeframe stays at 14 calendar days.

Expedited: no later than 72 hours after receiving the request.

Extension: up to 14 calendar days more, where the enrollee asks or the plan justifies a need for additional medical evidence in the enrollee’s interest, with notice to the enrollee.

Excludes: drugs.

Source: 42 CFR 422.568, 422.572, 422.122

Medicaid fee-for-service

Federal · from Jan 1, 2026

Standard: no later than 7 calendar days after receiving the request, unless a shorter minimum timeframe is established under state law.

Expedited: no later than 72 hours, subject to the same state-law clause.

Extension: up to 14 calendar days in the circumstances the regulation describes.

Excludes: outpatient drugs, which follow a separate statutory standard.

Source: 42 CFR 440.230(d)

Medicaid managed care

Federal · rating periods from Jan 1, 2026

Standard: the state-established timeframe may not exceed 7 calendar days after the plan receives the request, for rating periods beginning on or after January 1, 2026. Before that date the ceiling was 14 calendar days.

Expedited: no later than 72 hours after receipt.

Extension: up to 14 additional calendar days, with notice.

Excludes: drugs.

Source: 42 CFR 438.210(d)

CHIP fee-for-service and CHIP managed care

Federal · 2026 compliance dates

CHIP fee-for-service: on or after January 1, 2026, no later than 7 calendar days for a standard determination and 72 hours for an expedited determination, with a possible extension of up to 14 days.

CHIP managed care: entities must comply with the Medicaid managed care coverage and authorization requirements, with listed exceptions, so the same ceilings apply for rating periods beginning on or after January 1, 2026.

Excludes: drugs.

Source: 42 CFR 457.495(d), 457.1230(d)

Marketplace QHP on a Federally-facilitated Exchange

Federal rule — with an exclusion

Timeframes were not changed. CMS stated that it did not propose, and did not finalize, any change to prior authorization timeframes for QHP issuers on the Federally-facilitated Exchanges, in part because existing regulations already apply to them. Those plans remain subject to the internal claims and appeals rules: a pre-service claim decision within 15 days, and an urgent care claim as soon as possible and no later than 72 hours.

What did change: from January 1, 2026 a QHP issuer must give a specific reason when it denies a prior authorization request, and prior authorization metrics must be reported publicly.

Source: 45 CFR 156.223, 45 CFR 147.136, CMS-0057-F

Commercial and employer plans

No single federal deadline verified

CMS-0057-F does not reach commercial or self-funded employer coverage. Where the federal claims procedure rules apply, a pre-service claim decision is generally due within 15 days, extendable once by up to 15 days, and a claim involving urgent care is due as soon as possible and no later than 72 hours.

Also check: the plan document or provider manual, the contract, and the state utilization review law where the plan is insured rather than self-funded.

Source: 29 CFR 2560.503-1, 45 CFR 147.136

Original Medicare (fee-for-service)

Program-specific

Original Medicare has no general prior authorization requirement and no single deadline. It runs a limited set of prior authorization and pre-claim review initiatives, each with its own instructions. For hospital outpatient department services, regulation requires a provisional affirmation or non-affirmation within 7 calendar days of receipt, and within 2 business days for an expedited review where a delay could seriously jeopardize the beneficiary’s life, health or ability to regain maximum function.

Do not apply the CMS-0057-F timeframes here, and do not apply the outpatient department figures to the DMEPOS, ambulance or home health programs without checking those instructions.

Source: 42 CFR 419.82(d), CMS Medicare FFS compliance programs

What CMS-0057-F actually covers

Scope

The impacted payers are Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities and QHP issuers on the Federally-facilitated Exchanges. The prior authorization process policies carry 2026 compliance dates: January 1, 2026 for MA organizations and state Medicaid and CHIP fee-for-service programs, and the rating period beginning on or after January 1, 2026 for Medicaid and CHIP managed care. The application programming interface requirements come primarily in 2027.

The decision timeframes apply to covered items and services and exclude drugs, and they were not finalized for QHP issuers.

Source: CMS-0057-F, 89 FR 8758, CMS rule page

Drug Prior Authorization — Different Rules

This is the mistake worth avoiding: the 7-calendar-day and 72-hour deadlines finalized in CMS-0057-F do not apply to prescription drugs. CMS finalized those timeframes for prior authorization of covered items and services, excluding drugs. Drug requests run on their own rules, which are in some cases faster.

Medicare Part D

A Part D plan sponsor must notify the enrollee and the prescriber of a standard coverage determination no later than 72 hours after receiving the request, and an expedited determination no later than 24 hours. For an exceptions request the clock runs from receipt of the prescriber’s supporting statement.

Source: 42 CFR 423.568, 423.572

Part B drugs under Medicare Advantage

A request for a Part B drug must be decided no later than 72 hours (standard) or 24 hours (expedited) after receipt. The 72-hour period for a Part B drug request may not be extended.

Source: 42 CFR 422.568(b)(3), 422.572(a)(2)

Medicaid outpatient drugs

A state drug prior authorization program must provide a response by telephone or other telecommunication device within 24 hours of a request, and must provide for dispensing at least a 72-hour supply of a covered outpatient drug in an emergency situation.

Source: 42 U.S.C. 1396r-8(d)(5)

Commercial pharmacy benefits

No single federal deadline verified

A commercial drug request is usually handled by the plan’s pharmacy benefit manager under the plan’s own terms. Where the federal claims rules apply to the plan, an urgent pre-service claim is still due within 72 hours. State law may set something shorter for insured plans.

Source: 29 CFR 2560.503-1

A proposal is not a rule. In April 2026 CMS published a proposed rule that would extend electronic prior authorization and decision requirements to drugs for these payers. It is a proposed rule. Nothing in it is a current requirement, and it should not be quoted to a payer as though it were.

Standard vs Expedited Requests

Expedited handling is not a priority setting you can choose at will. Across these programs it applies where using the standard timeframe could seriously jeopardize the patient’s life, health or ability to regain maximum function. Three practical consequences follow.

  • The clinical reason belongs in the request. If a physician indicates that the standard timeframe would jeopardize the patient, the plan is generally required to expedite.
  • A downgrade is a decision. If the plan decides the request does not meet the expedited standard, it moves to the standard timeframe and must notify the enrollee. Get that in writing and diary the new date.
  • The expedited clock is in hours, not days. A 72-hour deadline runs from receipt, including weekends, so the hour a request is received matters.

Extensions and Exceptions

  • Medicare Advantage: up to 14 calendar days more on a standard or expedited request for an item or service, where the enrollee requests it or the plan justifies the need for additional medical evidence in the enrollee’s interest, with notice. An expedited Part B drug request cannot be extended.
  • Medicaid and CHIP: an extension of up to 14 calendar days where the enrollee or provider asks, or the plan or agency justifies a need for more information in the enrollee’s interest.
  • Plans under the federal claims rules: one extension of up to 15 days on a pre-service claim, for reasons beyond the plan’s control, with notice before the original period ends. For an urgent claim with missing information, the plan must say what is needed and allow at least 48 hours to provide it.
  • State law can shorten, not lengthen. The Medicaid rules are written as ceilings, “unless a shorter minimum timeframe is established under State law”.

What to Document When You Submit

Every deadline on this page runs from the date the payer received the request. If that date is not evidenced, the deadline cannot be enforced.

  1. Proof of receipt: the submission date and time, the channel used, and the payer’s confirmation, reference or tracking number.
  2. The request itself: which item, service or drug, and whether it was submitted as standard or expedited.
  3. The clinical basis: the documentation sent, and for an expedited request, the reason the standard timeframe would jeopardize the patient.
  4. Every follow-up: the date of each contact, the name of the person, and anything the plan said it still needed.
  5. The plan’s responses: extension notices, downgrades from expedited to standard, and the final decision with its date.

What to Do When the Deadline Passes

A missed deadline is not automatic approval, and it is not permission to bill as though the service were authorized. What it does is open a route.

  1. Confirm the receipt date and the applicable rule using the finder above, so you are working from the correct clock.
  2. Check whether an extension was invoked. A valid extension with notice changes the date; an extension asserted after the fact does not.
  3. Escalate inside the plan and ask for the decision in writing, noting the date the timeframe expired.
  4. Use the program’s appeal route. In Medicare Advantage, a failure to give notice within the required timeframe is treated as an adverse organization determination, which opens the appeal path. In Medicaid managed care, a failure to decide within the timeframe is treated as an adverse benefit determination, which starts appeal rights.
  5. Escalate outside the plan where appropriate: the state Medicaid agency for a Medicaid plan, the state insurance department for an insured commercial plan, or the relevant CMS route for Medicare Advantage.
  6. Do not assume the service is covered. Coverage and the decision timeframe are separate questions.

Denial Reasons and Next Steps

Beginning January 1, 2026, impacted payers under CMS-0057-F must give a specific reason when they deny a prior authorization request. CMS was explicit that this goes beyond quoting a single code: the payer must give enough detail for the provider to know what to do next — whether to appeal, submit more information, or take another route. The requirement excludes prior authorization decisions for drugs under that rule, and it sits alongside the notice requirements each program already has.

Operationally the reason matters because it tells you which of four different paths you are on:

  • Missing information: supply what was requested through the route the plan specifies, within any deadline it sets.
  • Wrong or incomplete submission: correct and resubmit where the plan allows resubmission — the hospital outpatient department programme, for example, expressly allows a resubmitted request.
  • A clinical or coverage decision: this is an appeal, not a resubmission, and the appeal deadline starts from the notice.
  • A benefit or eligibility problem: check the coverage itself, including which plan is primary, before anything else.

Not every denial can simply be resubmitted. Where the plan has made a determination on medical necessity or coverage, the appeal route is the one that preserves the patient’s rights and the claim.

State-Specific Rules

State law matters here, and this page deliberately does not publish a fifty-state table. The rules could not all be verified from official sources in this build, and an unverified table would be worse than none.

What is verified is where the federal rules hand authority to the states:

  • Medicaid fee-for-service: the 7-calendar-day and 72-hour timeframes apply “unless a shorter minimum timeframe is established under State law”.
  • Medicaid and CHIP managed care: the federal figures are ceilings on the state-established timeframe, so the state contract may be shorter.
  • Insured commercial plans: state utilization review law applies to the plans a state regulates. Self-funded employer plans are generally not subject to it.

One verified example. In Texas, the notice timeframes for utilization review agents are set by Insurance Code §4201.304, and the rule itself requires notice to the provider no later than one hour after the request when denying post-stabilization care following emergency treatment, and no later than three business days for a determination concerning an acquired brain injury, with that provision not applying to small employer plans. That is what the Texas rule states; it is cited here as an example of how state rules differ, not as a national standard.

For any other state, treat the rule as not verified here and check the state insurance department, the state Medicaid manual, or the state’s own administrative code.

Worked Examples

These are illustrative walk-throughs, not payer-specific commitments.

Example A — Medicare Advantage, medical service, standard

Situation: an MA plan receives a standard prior authorization request for an outpatient procedure on a Monday.

Rule: from January 1, 2026, a standard organization determination for an item or service subject to 42 CFR 422.122 is due no later than 7 calendar days after receipt, and sooner if the enrollee’s condition requires it.

Working: receipt Monday plus 7 calendar days gives the following Monday. Weekends are included because the rule counts calendar days.

If the plan extends: up to 14 calendar days more, but only in the circumstances the rule permits and with notice to the enrollee.

If the date passes with no decision: that failure is treated as an adverse organization determination, so the appeal route opens.

Example B — Medicaid managed care, and why the state matters

Situation: a Medicaid managed care plan receives a standard request in a rating period that began in March 2026.

Federal rule: the state-established timeframe may not exceed 7 calendar days after receipt for rating periods beginning on or after January 1, 2026.

The state layer: the federal figure is a ceiling. If the state contract or state law sets 5 days, 5 days is the deadline. The federal Medicaid fee-for-service rule says this in terms — “unless a shorter minimum timeframe is established under State law”.

What that means in practice: check the state contract before quoting 7 days to anyone, and diary the shorter of the two.

Example C — Commercial plan, and why no federal number applies

Situation: a commercial PPO receives a standard pre-service request.

Rule: CMS-0057-F does not reach this plan, so there is no 7-day federal deadline. Where the federal claims procedure rules apply, a pre-service claim decision is generally due within 15 days, with one 15-day extension available.

What decides the real answer: whether the plan is insured or self-funded. An insured plan is also subject to the state’s utilization review law, which is often shorter; a self-funded plan generally is not.

Correct next step: read the provider manual and the contract, then the state rule if the plan is insured. Do not apply a Medicare Advantage or Medicaid figure to it.

Common Questions

How long does prior authorization take?

It depends on who is reviewing it. For medical items and services, a Medicare Advantage plan has 7 calendar days for a standard request beginning January 1, 2026 and 72 hours for an expedited request. Medicaid fee-for-service, Medicaid managed care and CHIP have the same 7-day and 72-hour ceilings on their own compliance dates, and a state may require faster. Marketplace and commercial plans are not covered by those deadlines: where the federal claims rules apply, a pre-service decision is generally due within 15 days and an urgent one within 72 hours. Original Medicare has no single deadline and runs only a few program-specific prior authorization initiatives.

Does the 7 calendar day rule apply to every insurance company?

No. The 7-calendar-day standard and 72-hour expedited timeframes finalized in CMS-0057-F apply to the impacted payers named in that rule: Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans and CHIP managed care entities. CMS did not finalize any change to prior authorization timeframes for qualified health plan issuers on the Federally-facilitated Exchanges, and the rule does not reach commercial or self-funded employer plans or Original Medicare.

Do the CMS 2026 prior authorization deadlines apply to prescription drugs?

No. Those timeframes cover prior authorization for items and services and exclude drugs. Drug requests follow separate rules: a Part D plan must decide a standard coverage determination within 72 hours and an expedited one within 24 hours; a Medicare Advantage plan deciding a Part B drug request has 72 hours standard or 24 hours expedited; Medicaid must respond to an outpatient drug prior authorization request within 24 hours and allow at least a 72-hour emergency supply; and commercial pharmacy benefits follow the plan, the pharmacy benefit manager and any state law. A separate CMS rule on prior authorization for drugs was proposed in April 2026 and is a proposal, not current law.

When did the new prior authorization timeframes take effect?

CMS finalized compliance in 2026 for the prior authorization process policies: by January 1, 2026 for Medicare Advantage organizations and state Medicaid and CHIP fee-for-service programs, and for rating periods beginning on or after January 1, 2026 for Medicaid managed care plans and CHIP managed care entities. The application programming interface requirements in the same rule come later, primarily in 2027.

Can the payer extend a prior authorization deadline?

Often, yes, within limits set by the rule. A Medicare Advantage plan may extend a standard or expedited decision by up to 14 calendar days if the enrollee asks or if the plan justifies a need for more medical evidence that is in the enrollee’s interest, and it must give notice of the extension. Medicaid and CHIP rules allow a comparable extension of up to 14 days. An expedited Part B drug request cannot be extended. Under the federal claims rules that cover many commercial plans, a pre-service decision may be extended once by up to 15 days.

What happens if the plan misses the prior authorization deadline?

Missing the deadline is not treated as approval by default, and it is not a licence to bill. In Medicare Advantage, a failure to give timely notice of an organization determination itself constitutes an adverse organization determination (42 CFR 422.568(f)), which opens the appeal path. In Medicaid managed care, a service authorization decision not reached within the required timeframes constitutes a denial and is thus an adverse benefit determination (42 CFR 438.404(c)(5)), which starts appeal rights. The practical step is to document the receipt date and the missed deadline, escalate inside the plan, and use the appeal route the program provides.

Does the payer have to tell me why a prior authorization was denied?

Beginning January 1, 2026, impacted payers under CMS-0057-F must give a specific reason when they deny a prior authorization request, and CMS says that means enough detail for the provider to know what to do next. The requirement excludes prior authorization decisions for drugs under that rule. It sits alongside the existing notice requirements each program already has.

Is prior authorization required in Original Medicare?

For most items and services, no. Original Medicare runs a small number of prior authorization and pre-claim review programs instead, such as the hospital outpatient department program, certain DMEPOS items, repetitive scheduled non-emergent ambulance transport and home health review choice. Each has its own timeframe: in the outpatient department program, regulation requires a decision within 7 calendar days, or 2 business days for an expedited review.

Do state laws set shorter prior authorization deadlines?

They can, and several federal rules say so explicitly. The Medicaid fee-for-service rule sets its timeframes unless a shorter minimum timeframe is established under State law. State utilization review laws also apply to insured commercial plans, though not to self-funded employer plans. This page does not publish a fifty-state table because those rules could not all be verified from official sources; check the state’s own insurance department or Medicaid manual.

Does an expedited request have to be granted?

No. Expedited handling applies where using the standard timeframe could seriously jeopardize the patient’s life, health or ability to regain maximum function. If the plan decides a request does not meet that standard, it moves the request to the standard timeframe and must tell the enrollee. Document the clinical reason for the expedited request when you submit it.

Sources and Methodology

Every timeframe on this page was read in the regulation or in the final rule itself, not taken from secondary reporting. Where a figure could not be verified in an official source, the page says so rather than estimating.

No payer manual, CPT descriptor, X12 code description or model rule text is reproduced here. Explanations are original, and each rule links to its official source.

Limitations and Last Verified Date

  • Last verified: September 22, 2026, against the sources listed above.
  • Rules change. A proposed rule on drug prior authorization was published in April 2026, and compliance dates in CMS-0057-F continue into 2027. Check the source links before relying on a date.
  • State rules are not comprehensively covered. Only the Texas example above was verified. For every other state, treat the position as unverified here.
  • This page does not tell you whether a service needs prior authorization, which is a payer-by-payer question. It tells you how long the payer has once a request is in.
  • It is not legal advice, a coverage determination, or a guarantee of payment. The plan document, the contract and applicable law control.

To check whether a specific code may need authorization in the first place, use the PA Check lookup. Once the payer order matters, see primary vs secondary insurance. For claim filing deadlines after the service, see the timely filing limits reference. More free references are in the free tools hub.