Prior Authorization for Healthcare

Guide last updated: April 17, 2026. Hazard class: health and financial. Civic education by a Concerned Parent.

The short version

Prior authorization (also called "pre-auth," "PA," or "prospective review") is when your insurance requires approval before covering a specific service, medication, or procedure. Prior auth delays and denials are increasingly common and often reversible through appeals. Some states — including Illinois — have enacted prior authorization reform laws to speed decisions and limit scope. Acting fast and documenting medical necessity improves outcomes.

When prior authorization applies

Insurers typically require prior auth for:

Emergency services are generally not subject to prior authorization.

The process

  1. Provider submits request with clinical documentation
  2. Insurer reviews — often a utilization management nurse, then medical director for denials
  3. Decision — approval, partial approval, or denial; written notice provided
  4. If denied — right to appeal
  5. Multiple appeal levels — internal, external, sometimes regulatory

Illinois Prior Authorization Reform Act (2023)

Illinois enacted significant prior authorization reform in 2023:

The law primarily covers state-regulated plans. ERISA self-funded plans are not bound by state law, but are subject to federal prior authorization rules.

Appealing a prior authorization denial

Standard appeal timeline

  1. Internal appeal — most plans give 180 days to file. Insurer has 30-60 days to decide.
  2. Internal expedited appeal — for urgent conditions where delay would jeopardize health. 72-hour decision.
  3. External review — independent reviewer. 60 days from final internal denial. Binding on the insurer.

Winning appeals

Strengthen your appeal with:

Expedited review triggers

Request expedited review if:

Your doctor can request expedited review directly. Plans must decide urgent cases in 72 hours.

Step therapy and "fail-first" requirements

Step therapy requires you to try a cheaper drug before the insurer will cover a more expensive one. Illinois has some protections:

If your doctor believes step therapy is medically inappropriate, request an exception citing the specific clinical reasons.

Parity and prior authorization

If prior authorization requirements for mental health or substance use treatment are stricter than for medical care, that can be a violation of mental health parity law.

Common mistakes and how to avoid them

Don't get the treatment first and appeal later (if possible)

If you receive a service without prior authorization when one was required, the insurer may deny it entirely. Only in emergency or inadvertent cases is retrospective review available.

Keep records

Document every phone call: date, time, who you spoke with, what was said, any reference numbers.

Don't miss deadlines

Appeal deadlines (typically 180 days) are strict. Missing them forfeits your rights.

Involve your doctor

A peer-to-peer call between your physician and the insurer's medical director reverses many denials. Request your doctor's office to initiate.

Engage the insurer's case manager

Many insurers assign case managers for complex or expensive conditions. These are often allies in getting coverage.

Where to complain

Free help