HealthCare.gov: Prior Authorization and Appealing an Insurance Company Decision

Tier 1: Established: peer-reviewed research or government health authority
Publisher: U.S. Centers for Medicare & Medicaid Services (HealthCare.gov) · Published: September 17, 2026 · Accessed: September 17, 2026

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Claims this source supports

• Prior authorization means the health plan must approve certain services or prescriptions in advance before they are covered.
• If a plan denies a claim, the member can appeal; an internal appeal is a review by the plan, and if that is denied the member can generally request an external review by an independent third party.
• Appeals are subject to your plan's deadlines, and the denial notice states the reason for the denial and how to appeal.