The prior authorization process and payor decision deadlines

In the prior authorization process, the provider’s office does most of the work when it is in the patient’s network. Its staff send the request with the records the payor’s policy asks for and follow up until the payor decides. Since January 1, 2026, a federal rule, CMS-0057-F, has required Medicare Advantage plans and Medicaid and CHIP programs, including their managed care plans, to decide urgent requests within 72 hours and standard requests within 7 calendar days, according to the CMS fact sheet on the rule (January 17, 2024).

Those deadlines cover the payor’s decision only. MGMA notes that “a shorter regulatory decision deadline does not necessarily mean the entire authorization process is taking less time for the practice,” and 44% of the medical group leaders it polled said payor turnaround slowed in 2026, according to MGMA Stat (September 2, 2026).

At a glance

• Some plans make the patient responsible for the approval when the provider is out of network.
• A Medicare Advantage plan must decide an urgent Part B drug request within 24 hours.
• Insurers reported a median of about one day to decide a standard request in 2025.
• A manual request takes staff about 24 minutes on average, against 10 for a fully electronic one.
• A Medicare Advantage coordinated care plan cannot require a new approval for an active course of treatment during the first 90 days after a patient switches to it.

Steps in a prior authorization request

A request moves through the same stages with most payors, although each payor sets its own forms and submission channels.

1. Check whether the service needs approval. Confirm the patient’s coverage first, as Silna’s insurance verification process guide describes, then check whether the payor requires prior authorization for the service code under that plan.
2. Send the request with its records. The request carries the clinical records the payor’s policy asks for. Silna’s guide to getting a prior authorization approved covers how to prepare one.
3. Wait for the payor’s decision. The payor approves the request, denies it or pends it to ask for more information. A pended request does not move until the practice sends what was asked for.
4. Schedule within the approval. An approval names the services, the number of visits or units and the dates it covers, and the care has to fall inside them.
5. Respond to a denial. The treating provider can ask for a peer-to-peer review with the payor’s reviewer or file an appeal, as Silna’s guide to appealing a prior authorization denial explains.

Let Silna submit your requests and follow up with each payor

Responsibility for getting prior authorization

No federal rule says who must get the prior authorization, so the answer comes from each plan’s own terms. Plans such as Cigna and Moda Health put it on the provider when the provider is in the patient’s network. Cigna tells its members (page updated July 22, 2026): “If your health care provider is in-network, they will start the prior authorization process. If you don’t use a health care provider in your plan’s network, then you are responsible for obtaining the prior authorization.”

Plans also decide who pays when the step is skipped. Moda Health tells its members that an in-network provider who gives a service without prior authorization is financially responsible for it, and that a member who sees an out-of-network provider without an approval is responsible instead.

Prior authorization decision deadlines and wait times

Federal rules set decision deadlines for Medicare Advantage, Medicaid and CHIP, and state laws set them for many of the plans each state regulates.

Insurers already answered faster than those limits in 2025. In KFF’s analysis of the data insurers published (August 13, 2026), the median decision on a standard request took about one day in Medicare Advantage, Medicaid managed care and Marketplace plans. Expedited requests took a median of just under 10 hours in Medicare Advantage, about 19 hours in Medicaid managed care and one day in the Marketplace. KFF measured these while the standard limit was 14 calendar days in Medicare Advantage and Medicaid managed care and 15 in the Marketplace, and half of requests took longer than the median.

For a practice, the answer to “how long does it take to get a prior authorization” also includes its own work before and after the payor’s decision. A prior authorization takes providers 24 minutes on average when it is done manually by phone, fax or email, 16 minutes through a portal and 10 minutes when it is fully electronic, according to the 2024 CAQH Index (January 2025). Practices in MGMA’s September 2026 poll that reported slower turnaround most often named status checks and peer-to-peer reviews among the bottlenecks.

What to track after an approval

An approval covers set services, units and dates, so the practice keeps a record of each one:

• The authorization number
• The approved service codes and the number of visits or units
• The start and end dates
• The visits or units used so far
• The date to request a renewal

A plan change mid-treatment needs its own check. Medicare Advantage coordinated care plans must give a patient in an active course of treatment a transition period of at least 90 days after switching plans, under CMS-4201-F, according to the CMS fact sheet (April 5, 2023). Plans in the AHIP prior authorization pledge (June 23, 2025) committed that from January 1, 2026, when a patient changes insurance companies during a course of treatment, the new plan will honor existing approvals for benefit-equivalent in-network services for 90 days.

How Silna tracks a request from submission to decision

Silna’s work covers prior authorizations under medical and behavioral health benefits. It lists the authorizations each patient will need next and sends weekly reminders. After it submits a request, it follows up with the payor until the payor decides. Before a request goes out, Predictive Document Intelligence compares it with the payor’s requirements and flags what is missing.

Zion Physical Therapy reports an average authorization turnaround of 4 days with Silna. G2 reviewers rate Silna 4.8 out of 5 across 66 verified reviews, and it is the #1 rated prior authorization solution there.

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Key terms

Pended request

A request the payor has paused while it waits for more information from the practice.

Peer-to-peer review

A call between the treating provider and the payor’s clinical reviewer about a request that was denied or is about to be.

Urgent (expedited) request

A request where waiting the standard time could seriously harm the patient’s health, which gets a shorter decision deadline.

Authorization number

The reference a payor issues with an approval, which links the scheduled service and its claim to that decision.

CMS-0057-F

The CMS Interoperability and Prior Authorization Final Rule of January 2024, which set decision deadlines from 2026 and requires a prior authorization API from 2027.

Frequently Asked Questions

Who is responsible for getting pre authorization?

Usually the provider, when it is in the patient’s network. Cigna puts the task on the member only when the provider is out of network.

How long does prior authorization take for an urgent request?

Up to 72 hours with Medicare Advantage plans and Medicaid and CHIP since January 2026. For a Part B drug, a Medicare Advantage plan has 24 hours.

How long do prior authorizations take for a standard request?

Up to 7 calendar days with the plans CMS-0057-F covers. State-regulated commercial plans follow state law, which the AMA’s state law chart compares.

How does prior authorization work when a patient changes plans?

The new plan’s rules apply, and it may ask for a new approval. A Medicare Advantage coordinated care plan has to wait at least 90 days before it asks for one for a treatment already under way.

How long is a prior authorization good for?

For the dates and units the approval names. In Medicare Advantage, an approval for a course of treatment stays valid as long as the treatment is medically necessary, according to Medicare.gov.

This article is general educational information and does not give medical, legal or insurance advice. Payor rules and state laws change, so check the current policy with the patient’s plan before you rely on a deadline.

About the author

Jeffrey Morelli

Jeffrey Morelli is the Co-Founder and CEO of Silna Health, the first Care Readiness Platform built to remove the administrative barriers that delay care. Silna automates benefit checks, eligibility, and prior authorizations across 1,000+ payors, and is backed by $27M from Accel and Bain Capital Ventures. Before Silna, Jeff spent a decade in San Francisco building and scaling products for highly regulated industries, including leading go-to-market at Truework (Series C, acquired by Checkr).

Last updated: October 29, 2026.