My prior authorization was denied — what do I do next?

Use the free tool — Health Plan Denial Appeal

What a prior authorization denial means

Your plan said no before you got the service. That does not mean the answer is final. About half of appealed denials get overturned — and almost nobody appeals. The letter often hides the real reason behind a code, and hides the deadline in fine print.

Find the real reason

The denial reason is usually one of these:

Medical necessity
Prior authorization not obtained or not approved
Out-of-network
Coding error
"Experimental" treatment

Read the letter closely. It should say which of these applies, but often the language is technical rather than plain.

Your appeal rights and deadlines

Under the ACA and Florida law, you generally have two chances to appeal:

Internal appeal: 180 days from the date on the denial letter.
External review: 4 months from the date on the denial letter.

Confirm these exact dates using the date printed on your own letter, and check with your plan to be sure. This is not legal advice.

What to request from the plan

Ask the plan for:

The clinical criteria used to deny the request
The reviewer's credentials
The specific guideline used to make the decision
Any documents the plan must give you free of charge

Build your appeal letter

A strong appeal letter should include:

The clinical criteria the plan is required to consider
Your doctor's medical-necessity rationale
The prior-authorization facts (dates, service, codes)
A request for the reviewer's credentials and the guideline used

Your doctor can sign this letter once it reflects the medical-necessity points accurately.

What this does not cover

This guidance is for employer, ACA marketplace, and individual health plans. It does not cover Medicare, Medicare Advantage, or Medicaid fee-for-service — those have separate appeal systems. If your denial is from Medicare, use Medicare Decoder instead.

This is not legal or medical advice. For free help, contact the Florida Division of Consumer Services at 1-877-693-5236, or for employer plans, the U.S. DOL EBSA at 1-866-444-3272.

What to do next

Paste your denial letter or explanation of benefits into the free tool. It reads your own document and numbers — the date, reason code, service, and plan type — and gives you the real reason in plain words, both appeal deadlines already computed from your letter's date, the records to request, and a draft appeal letter your doctor can sign.

Use the free tool

Health Plan Denial Appeal is an informational tool for commercial (employer, ACA marketplace, individual) health plan denials, based on the ACA (45 CFR 147.136), ERISA claims rules (29 CFR 2560.503-1) and Florida Statutes 627.6472 / 627.602 as of 2025–26. It does not cover Medicare, Medicare Advantage or Medicaid fee-for-service, which have their own appeal systems. It is not legal or medical advice and does not file appeals. It is not affiliated with any insurer, employer or agency.