Medicare Advantage Prior Authorization Denied: What to Do
Get the written reason, involve the treating clinician and decide whether the request needs missing information, resubmission or a formal reconsideration.
A denial should explain what the plan decided
A Medicare Advantage decision about authorization or payment is an organization determination. When the plan denies medical coverage or payment, it should issue a written denial notice explaining the reason and appeal rights. Preserve that notice; a portal message saying “not approved” may not contain everything needed to respond.
Before appealing, find out what failed
Missing or incomplete information
The plan may not have received clinical notes, imaging, diagnosis information, therapy history or the correct authorization form. Ask the provider what was submitted and what the plan says is missing.
Coverage criteria not demonstrated
The reviewer may believe the records do not show that the service meets Medicare, plan or internal medical-necessity criteria. Ask for the exact criterion used.
Network or referral problem
The requested facility or clinician may be outside the network, or the plan may require a referral. Review the exact plan network and referral rules rather than relying on the provider’s general statement that it “takes Medicare.”
Different service suggested
The plan may require a less intensive setting, alternative treatment or additional step first. The clinician should explain why the requested option is medically appropriate if an alternative is not suitable.
These problems do not always call for the same response. Correcting a missing fax is different from challenging a medical-necessity denial. Do not let repeated resubmissions consume the appeal deadline.
Prior authorization decisions and appeals use different clocks
Beginning in 2026, impacted payers including Medicare Advantage organizations generally must send decisions on medical-item and service prior authorization requests within seven calendar days for standard requests and 72 hours for expedited requests. They must also provide a specific reason for denying a request.
After an adverse decision, the level-one Medicare Advantage appeal is a reconsideration. The beneficiary, representative or clinician generally has 65 days from the date on the initial denial notice to request it.
| Appeal type | Plan decision timeframe | When it generally applies |
|---|---|---|
| Standard pre-service appeal | 30 days | A service has not yet been received and the case does not qualify for expedited review |
| Fast pre-service appeal | 72 hours | Waiting could seriously jeopardize life, health or the ability to regain maximum function |
| Payment appeal | 60 days | The service was already received and the dispute concerns plan payment |
| Part B drug appeal | 7 days | The denial concerns a Part B-covered drug under the medical benefit |
Some timeframes may be extended in limited circumstances. The plan must explain an extension and your rights. Part D outpatient prescriptions follow a separate process covered in our Part D drug denial and appeal guide.
What to do after the denial
- Get the complete written notice. Look for the Notice of Denial of Medical Coverage or Payment and the specific reason, appeal address and filing deadline.
- Call the ordering provider. Ask whether the plan received the full request and whether the provider agrees that the requested care remains appropriate.
- Request the criteria or policy. Ask what Medicare coverage rule, plan rule or internal criterion was applied and how the record failed to meet it.
- Choose correction, resubmission or appeal. A clerical omission may be corrected; a disputed adverse determination may require reconsideration. Sometimes both tracks proceed while the deadline is preserved.
- Ask for expedited review when medically justified. The provider’s statement that the standard timeframe could seriously harm health is important to the fast-review request.
- Submit focused evidence. Include the denial, clinical records, prior treatment results and a short clinician explanation connecting the facts to the coverage criteria.
The treating clinician is central to a medical-necessity case
A broker can help locate plan contacts and explain plan terminology, but the treating clinician supplies the medical reasoning. Ask the office to address:
- The diagnosis and requested service
- Why the service is reasonable and necessary now
- Conservative or alternative treatments already tried
- Why a plan-suggested alternative is inappropriate, if applicable
- The risk of delay
- The coverage criterion each record supports
Keep the appeal narrow
A strong submission responds directly to the stated reason for denial. Sending hundreds of unorganized pages without identifying the relevant facts can make the issue harder to see.
What if the issue is the provider or facility?
Confirm the exact plan, contract year, provider location and service—not merely the health system’s name. A hospital may participate while an associated physician, clinic or facility does not. Our guide to a Medicare plan losing a doctor or hospital explains the difference between network disruption and an individual authorization denial.
If a plan provider directs you to a covered service or outside provider without obtaining an organization determination in advance, ask the plan whether plan-directed-care protections apply.
Do not delay emergency care to wait for authorization
Prior authorization procedures should not be used as a reason to postpone emergency evaluation. For an emergency, call 911 or seek emergency care. Coverage and payment questions can be addressed after immediate safety needs.
Prior authorization denial FAQs
Is a prior authorization denial the same as a claim denial?
Not always. Prior authorization usually concerns approval before a service. A claim denial concerns payment after billing. Both can be organization determinations, but the evidence and decision timeframes can differ.
How long does a Medicare Advantage plan have to decide a prior authorization?
For medical items and services, impacted payers generally must send decisions within seven calendar days for standard requests and 72 hours for expedited requests beginning in 2026.
How long do I have to appeal a Medicare Advantage denial?
A level-one reconsideration generally must be requested within 65 days from the date on the initial denial notice. Follow the specific instructions on your notice.
Can my doctor request the appeal?
For a service you have not received, your clinician may request reconsideration on your behalf and must notify you. The clinician can also provide the medical records and reasoning needed for the case.
When can I request a fast Medicare Advantage appeal?
Ask for expedited review when waiting for the standard decision could seriously jeopardize life, health or the ability to regain maximum function. The plan must expedite when it determines, or the doctor states, that the standard timeframe creates that risk.
Will the plan automatically send the case to an independent reviewer?
If the plan upholds a Medicare Advantage denial at level one, it generally forwards the case automatically to the Independent Review Entity for level-two review.
Can I file a grievance about the prior authorization process too?
Possibly. An appeal challenges the coverage decision; a grievance addresses service, delay or administrative quality. Review our appeal versus grievance guide because the two processes address different problems.
Official sources
Need help organizing the plan questions?
Thompson Medicare Brokerage provides year-round plan support in Missouri and Illinois. We can help identify the proper plan department and documents, while the treating clinician and plan handle the medical review and appeal decision.