What to Do When a Claim Is Denied for Prior Authorization

Get the authorization history

Ask the ordering provider and insurer for the request date, decision, authorization number, approved service, provider or facility, date range, and any limits. Compare these details with the actual claim. A referral and an authorization may be different requirements.

References: HealthCare.gov: Preauthorization

Choose the branch that matches the denial

Use the actual denial language to choose your next question. “No authorization on file” and “not medically necessary” are different problems, even when they concern the same procedure.

• No request found: ask the ordering office for proof of submission and the insurer’s response.
• Approved request, denied claim: compare the authorization and claim details side by side.
• Request denied on clinical grounds: ask your clinician which records address the stated criteria.
• Decision still pending: confirm whether information is missing and when the plan expects a decision.
• Care is urgent: ask your clinician and plan about the applicable expedited process; do not postpone necessary care solely to follow this checklist.

If approval existed, check for a mismatch

Ask the billing office whether the claim used the correct authorization reference and whether the service, dates, or units differed from approval. A corrected claim may be appropriate when the submitted information is inaccurate. Do not ask anyone to change an accurate code solely to obtain coverage.

Worked example: approval and claim name different facilities

Illustrative example only: an approval letter names Facility A, but you received the service at Facility B. The claim is then denied for an authorization mismatch. A letter approving Facility A does not establish that Facility B was approved.

Ask the ordering office whether it requested a location change and ask the insurer whether a change was recorded. If the claim incorrectly names Facility B when you actually attended Facility A, ask the provider to investigate that factual error. If you did attend Facility B, ask about the plan’s review or appeal process for what actually happened. Never ask the office to substitute a false location.

• Compare approved and billed service, facility, clinician, dates, units, and authorization number.
• Keep any appointment-change messages and updated authorization letters.
• Ask whether the proposed provider review preserves your member appeal deadline; do not assume it does.

If approval was missing, ask about the applicable rule

Request the plan language showing that authorization was required for that service on that date. Ask whether the plan permits retrospective review or another correction process. Availability varies; approval after care is not automatic. Ask the provider and plan whether provider contract rules limit what can be billed to you.

If the request itself was denied, address that reason

A clinical denial needs different evidence from a missing reference number. Ask your clinician to help explain the need for care and provide relevant records. For upcoming care, clarify alternatives and urgency with the clinician; do not rely on a billing guide to make treatment decisions.

Protect the appeal deadline

Ask whether a provider resubmission or clinical discussion counts as a formal appeal. Follow the denial notice if it does not. Preserve the authorization history, claim details, and proof of appeal submission. Emergency care may have different authorization rules; ask the plan to explain how those rules apply.

References: U.S. Department of Labor: Filing a claim for your health benefits · HealthCare.gov: Getting emergency care

What to say when each office says the other must fix it

“I need to establish whether authorization [number] covered the actual service on [date]. Please identify the specific field or coverage requirement causing the denial, the document needed to resolve it, and which team must submit it. If this requires a formal appeal, please give me its submission instructions and deadline.”

For a clinical denial, ask the treating clinician to connect the relevant records to the insurer’s stated concern. For a missing or mismatched authorization record, start with the authorization and claim history. Keep the answer focused on the identified reason rather than sending unrelated medical records.