How Long Does Prior Authorization Take? Deadlines by Payer Type

Published October 29, 2026

TL;DR

  • There is no single answer. The legal decision deadline depends on who regulates the plan: Medicare Advantage, Medicaid and CHIP now have a 7 calendar day standard and 72 hour expedited limit for most non-drug requests, while ERISA employer plans have 15 days for pre-service claims and 72 hours for urgent care.
  • Since January 1, 2026, CMS-0057-F has applied the 7 day and 72 hour limits to Medicare Advantage organizations and state Medicaid and CHIP programs, and to Medicaid managed care plans for rating periods starting on or after that date. QHP issuers on the federal exchanges and all drug requests are excluded.
  • A deadline is not a guarantee of speed. Most federal rules allow an extension of up to 14 calendar days when more information is needed, and some state laws do not start the clock until the payer has everything it needs.
  • The 2025 AMA physician survey found an average of 40 prior authorizations per physician per week and 13 hours of physician and staff time spent on them, so the time a request sits pended matters as much as the payer's official clock.

A front-desk scheduler asks the question every week: the patient wants a date for the MRI, so how long will the authorization take? The honest answer is that it depends on the patient's coverage, and the difference between plan types is not small. One plan may owe a decision within 72 hours, another within 15 days, and a third may not be on any clock until its reviewer has every record it asked for.

This guide sets out the decision deadlines that apply to the main payer types in 2026, where those deadlines come from, and why requests still run long when every payer is technically in compliance.

The deadline depends on who regulates the plan

Prior authorization timeframes are set by whoever regulates the coverage. Medicare Advantage, Medicaid and CHIP follow federal CMS rules. Employer plans covered by ERISA follow Department of Labor claims procedure rules. Fully insured commercial plans are also subject to state insurance law, which can set its own, sometimes shorter, limits.

That means the first step in estimating turnaround is identifying the coverage correctly. A commercial card from a national carrier could represent a fully insured policy, a self-funded employer plan the carrier only administers, or a Medicare Advantage product, and each sits under a different rule. Delegated vendors add another layer: when a radiology or specialty benefit manager reviews the request on the plan's behalf, the plan's deadline still governs, but the request runs through the vendor's queue. Our guide to delegated utilization management explains how to tell who is actually reviewing.

Medicare Advantage, Medicaid and CHIP: 7 days and 72 hours

CMS's Interoperability and Prior Authorization final rule, CMS-0057-F, was published on February 8, 2024. For Medicare Advantage, 42 CFR 422.568 now says that beginning on or after January 1, 2026, a standard decision on a service or item subject to the plan's prior authorization rules is due "7 calendar days after receiving the request." Before 2026 the standard limit was 14 calendar days, and that 14 day limit still applies to items and services that are not under the plan's prior authorization rules. Expedited organization determinations are due no later than 72 hours after the plan receives the request.

The same 7 day and 72 hour structure now applies across the other programs the rule calls impacted payers:

CoverageStandard decisionExpedited decisionStarts
Medicare Advantage (42 CFR 422.568, 422.572)7 calendar days72 hoursJanuary 1, 2026
Medicaid managed care (42 CFR 438.210(d))7 calendar days72 hoursRating periods starting on or after January 1, 2026
CHIP (42 CFR 457.495)7 calendar days72 hoursJanuary 1, 2026
Medicaid fee-for-service (42 CFR 440.230(e))7 calendar days72 hoursJanuary 1, 2026
QHP issuers on the federal exchanges15 days72 hoursUnchanged by CMS-0057-F

Two details in that table matter for scheduling. Medicaid managed care plans pick up the 7 day limit by rating period, so a plan whose rating period starts mid-year may have adopted it after January. For CHIP, 42 CFR 457.495 also lets a state follow its existing prior authorization law instead of the 7 day and 72 hour limits. QHP issuers on the federal exchanges were explicitly left out of the new timeframes; the final rule notes they already had to decide standard requests within 15 days and expedited requests within 72 hours. The rule's prior authorization provisions do not apply to drugs at all.

The rule also requires a specific reason for every denial and annual public reporting of prior authorization metrics, including average and median decision times. The first reports, covering 2025, were due March 31, 2026. We looked at what those reports show, and what they leave out, in what the first public prior authorization reports show.

Part D drugs move on a faster clock

Medicare Part D coverage determinations are not covered by CMS-0057-F, and they already run faster than the medical-benefit rules. Under 42 CFR 423.568, a plan sponsor must decide a standard coverage determination within 72 hours of receiving the request, and under 42 CFR 423.572 an expedited request within 24 hours.

Exceptions requests, such as a request to cover a drug that is not on the formulary, start their clock differently. The 72 or 24 hours run from receipt of the prescriber's supporting statement, not from the original request. If the sponsor misses the deadline, the regulation treats that failure as an adverse determination and requires the sponsor to send the case to the independent review entity within 24 hours, which is worth knowing before a team spends a week chasing a status that has already legally become a denial.

Original Medicare has its own programs and timeframes

Traditional Medicare does not use prior authorization for most services, but several CMS programs require it. For the hospital outpatient department prior authorization program, CMS changed the standard review timeframe from 10 business days to 7 calendar days for requests submitted on or after January 1, 2025, and expedited requests remain at 2 business days. CMS made the same change for certain durable medical equipment, prosthetics, orthotics and supplies.

The WISeR model, which began January 1, 2026 in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington, adds prior authorization for selected services in those states. Its operational guide says participants will "typically" issue a determination within 3 calendar days, and within 2 days for accepted expedited requests. That is operational guidance rather than a regulatory deadline, so treat it as an expectation, not a limit you can enforce. The differences between the two Medicare paths are covered in our guide to Medicare Advantage vs. Traditional Medicare.

ERISA employer plans: 15 days for pre-service claims

Most private-sector employer plans are governed by ERISA, and the Department of Labor's claims procedure regulation at 29 CFR 2560.503-1 treats a prior authorization request as a pre-service claim. The plan must decide a pre-service claim within 15 days of receiving it, and it may extend that once by up to 15 days for reasons beyond its control. Urgent care claims are due within 72 hours.

ERISA is unusually explicit about missing information. The clock begins when the claim is filed, without regard to whether everything needed accompanies it. If the plan needs more, it must say exactly what is missing, the claimant gets at least 45 days to provide it, and the decision clock is paused from the date the plan sends that notice until the response arrives. For urgent claims, the plan must identify what is missing within 24 hours, give the claimant at least 48 hours to respond, and decide within 48 hours of receiving the information or of the end of that response period, whichever is earlier.

State laws can start the clock later

For fully insured plans, state prior authorization laws add their own deadlines, and some count from a different starting point. Illinois's Prior Authorization Reform Act, effective January 1, 2022, requires a decision on a non-urgent request no later than 5 calendar days after the insurer obtains all necessary information, and on an urgent request within 48 hours of receiving all the information it needs. Illinois also requires a denial notice to describe any missing or insufficient documentation.

That wording is the practical issue. A deadline that starts when the payer has "all necessary information" can be met on paper while the request sits for weeks waiting on a chart note. State laws vary in their timeframes and triggers and change often, so confirm the current statute or the state insurance department's guidance before quoting a state deadline to a patient.

Why requests take longer than the rules suggest

The federal limits are ceilings for a decision, not estimates of total elapsed time. Medicare Advantage, Medicaid and CHIP rules all allow a standard decision to be extended by up to 14 calendar days in defined circumstances, such as when the payer needs more information, which turns a 7 day clock into as many as 21. The extension is visible in the public data too: CMS-0057-F requires payers to report the percentage of requests where the review timeframe was extended.

Most of the delay providers feel happens around the decision rather than inside it. A request submitted without the documentation the reviewer needs gets pended, a records request goes to a fax queue, and nobody notices until the patient calls to ask about the appointment. When a reviewer wants to discuss the case, the timing of a peer-to-peer review adds another dependency. Inpatient stays run on a separate cadence of notifications and updates, covered in our guide to concurrent review.

The volume behind those delays is large. In the AMA's 2025 prior authorization physician survey of 1,000 physicians, physicians reported completing an average of 40 prior authorizations per week, consuming an average of 13 hours of physician and staff time. Ninety-five percent said prior authorization delays access to necessary care.

How to set expectations and keep requests moving

A useful turnaround estimate combines the payer's legal clock with the practice's own history for that payer and service. Teams that track it well tend to record the same few things on every request:

  • the coverage type and the rule that governs it, including any delegated vendor;
  • the date and channel of submission, and the reference number the payer assigned;
  • every pend or request for more information, with the date it arrived and the date it was answered;
  • whether the payer took an extension, and the new due date;
  • the decision date, the decision, and the specific reason for any denial.

Checking status before the deadline, rather than after the appointment is at risk, is where most of the time is recovered. If a status check shows a pend, the useful question is what exactly is missing and where to send it, not when a decision is coming.

Status checks still often mean a phone call, because portal and electronic status responses do not always explain a pend. SuperDial's voice agents handle that payer follow-up for prior authorization teams, returning the status, reference number and next step as structured data with a recording and transcript.

A note on what is changing next

Two developments may shorten some of these timelines further, though neither is settled law. On June 23, 2025, health plans announced voluntary commitments through AHIP, including a goal that in 2027 at least 80 percent of electronic prior authorization approvals "with all needed clinical documentation" will be answered in real time. And CMS's proposed rule CMS-0062-P, published April 14, 2026, would extend prior authorization decision deadlines to QHP issuers on the federal exchanges, including deadlines for drug requests; as of October 28, 2026 it remains a proposal, as our explainer on the CMS drug prior authorization proposal describes.

FAQ

How long does prior authorization take for Medicare Advantage?

For items and services subject to the plan's prior authorization rules, a Medicare Advantage organization must make a standard decision within 7 calendar days of receiving the request, starting January 1, 2026, and an expedited decision within 72 hours. The plan may extend either timeframe by up to 14 calendar days in defined circumstances.

How long does a commercial insurance prior authorization take?

It depends on how the plan is funded and regulated. ERISA employer plans must decide pre-service claims within 15 days, with one possible 15 day extension, and urgent claims within 72 hours. Fully insured plans may also be bound by a state law, such as Illinois's 5 calendar day limit after all necessary information is received.

Does the 7 day rule apply to prescription drugs?

No. CMS-0057-F's prior authorization provisions do not apply to drugs. Medicare Part D coverage determinations have their own limits of 72 hours for standard requests and 24 hours for expedited requests.

What happens if a payer misses the deadline?

For Medicare Advantage, a missed deadline is itself an adverse determination that can be appealed. For Part D, it is an adverse determination and the plan must send the case to the independent review entity within 24 hours. Other plan types handle it differently, so check the plan's appeal rights and any state law that applies.

Why is my prior authorization still pending after the deadline?

Usually because the payer extended the timeframe or pended the request for more information. Ask what specific information is missing, where to send it, and the new due date, and record the reference number for the call.

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