Prior Authorization and Referrals: Getting Care Approved First

Some care needs a green light before you get it. Your plan may require prior authorization, a decision that a service, treatment, drug or piece of equipment is medically necessary, or a referral, a written order from your primary care doctor to see a specialist. Skip either step when your plan requires it, and the plan may refuse to pay.

These rules are easy to overlook because they live in plan documents most people never read until something goes wrong. Knowing when approval is needed, how long a decision should take and what protections you have can save you from a denied claim, or help you reverse one.

This guide explains the general federal rules for private health coverage as of October 2026. It is general information, not medical, insurance or legal advice. Your plan documents and your insurer decide what your plan requires, and Medicare and Medicaid have their own rules.

Prior authorization and referrals are different things

HealthCare.gov defines preauthorization as "a decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary." It is also called prior authorization, prior approval or precertification. Two points in that definition matter: a plan may require it before you receive certain services, except in an emergency, and preauthorization "isn't a promise your health insurance or plan will cover the cost." The claim can still be checked against your benefits, network and eligibility later.

A referral is different. HealthCare.gov describes it as a written order from your primary care doctor for you to see a specialist or get certain medical services. It notes that many HMOs require a referral before you get care from anyone except your primary care doctor, and that without one the plan may not pay.

In short, a referral usually comes from your doctor and gives you permission to see someone; prior authorization comes from your plan and approves a specific service.

When you do not need approval

Federal regulations for most job-based and individual plans (45 CFR 147.138) set some important limits:

• Emergency care: if a plan covers emergency department services, it must cover emergency services without any prior authorization, even if the services are out of network.
• OB-GYN care: a plan that requires you to designate a primary care provider may not require authorization or a referral for obstetrical or gynecological care from an in-network professional who specializes in obstetrics or gynecology. That specialist may still need prior authorization for certain services or have to follow the plan's referral procedures.
• Choosing a primary care provider: if your plan requires you to designate one, you can pick any participating primary care provider who is available to accept you, and you can choose an in-network pediatrician as your child's primary care provider.

Grandfathered plans may not include all of these protections, so check your plan's materials if you are unsure.

How long a decision should take

For job-based plans covered by ERISA, the U.S. Department of Labor (DOL) treats a prior authorization request as a pre-service claim. As of 2026, DOL says:

• Standard pre-service requests must be decided within a reasonable time and no later than 15 days after the plan receives the request; the plan may extend that by up to 15 days for reasons beyond its control, if it tells you before the first period ends.
• Urgent requests must be decided as soon as possible and no more than 72 hours after the plan receives them.
• If a physician with knowledge of your condition tells the plan a pre-service claim is urgent, the plan must treat it as urgent.

As of October 2026, HealthCare.gov likewise says an insurer must notify you in writing within 15 days if you are seeking prior authorization, and within 72 hours for urgent care.

Public programs are on a different track. Under a CMS rule announced on January 17, 2024 (CMS-0057-F), generally starting January 1, 2026, Medicare Advantage plans, Medicaid and CHIP programs and their managed care plans must decide prior authorization requests within 72 hours for expedited requests and seven calendar days for standard requests, and must give a specific reason when they deny one. CMS notes those decision timeframes do not apply to Qualified Health Plan issuers on the federally facilitated Marketplaces, and the rule's prior authorization policies do not apply to drugs.

Before a scheduled test, procedure or specialist visit

A little checking up front prevents most problems:

1. Look in your plan documents, such as the Summary of Benefits and Coverage, for services marked as requiring prior authorization or a referral.
2. Ask your doctor's office whether a request is needed and whether it has been submitted. Do not assume it has.
3. Get the approval details: a reference number, the dates it covers, the number of visits or units approved and the provider or facility named.
4. Confirm that the provider and facility are in your network. Approval for a service does not make an out-of-network provider in-network.
5. Watch the end date. Approvals can expire, and a rescheduled procedure may need a new one.
6. If your plan requires a referral, make sure it is on file before the specialist visit and that it covers any follow-up visits.

For example, imagine someone in an HMO whose doctor suggests an MRI and a visit with an orthopedic specialist. They might need a referral for the specialist and a separate prior authorization for the MRI, and both need to be in place before the appointments.

If a request is denied

A prior authorization denial is a denial of a claim, so you have appeal rights. Read the denial notice for the specific reason and the deadline to appeal. Your doctor can often help by sending records or a letter explaining why the service is medically necessary for you. If your situation is urgent, say so, and ask your doctor to tell the plan; HealthCare.gov says that in urgent situations you can request an external review at the same time as an internal appeal. Our guide "Appealing a Denied Health Claim: Internal Appeals and External Review" covers the full process and deadlines.

Watch for scams, too. The FTC warns not to give your medical information to someone who calls, emails or texts you unexpectedly, because it could be a scammer. If a message claims to be about approving your care, contact your plan using the number on your insurance card.

Where to get help

Your plan's member services line, listed on your card, can tell you which services need approval. If you hit a wall, your state's Consumer Assistance Program, if your state has one, or your state insurance department may help; CMS keeps a map of these programs. For most private employer plans, DOL's Employee Benefits Security Administration answers questions at 1-866-444-3272. If you have Medicare, your State Health Insurance Assistance Program (SHIP) offers one-on-one counseling.

Key takeaways

• Prior authorization is your plan's advance approval of a service; a referral is your primary care doctor's order to see a specialist.
• Prior authorization is not a promise of payment, and emergency care cannot require it under federal rules for most plans.
• Plans that require a primary care provider cannot require a referral for in-network OB-GYN care.
• For job-based plans, DOL says standard pre-service decisions are due within 15 days and urgent ones within 72 hours.
• Get approval details in writing, check network status, and appeal a denial with your doctor's support.

Sources

• HealthCare.gov, Preauthorization (glossary)
• HealthCare.gov, Referral (glossary)
• Electronic Code of Federal Regulations, 45 CFR 147.138 Patient protections
• U.S. Department of Labor, Employee Benefits Security Administration, Filing a Claim for Your Health Benefits
• HealthCare.gov, Internal appeals
• CMS, CMS Interoperability and Prior Authorization Final Rule CMS-0057-F (fact sheet)
• CMS, Consumer Assistance Grants (state Consumer Assistance Programs)
• Federal Trade Commission, What To Know About Medical Identity Theft