Prior authorization is the sixth of the 10 Exits of Therapy™, and it is the one where everybody assumes somebody else is watching the calendar.
There is a deadline on your request. It starts when the request reaches your plan, not when your prescriber’s office says they sent it, and you are entitled to ask for both dates by name.
What is actually happening while you wait
Your prescriber writes a prescription. Your plan says it will not pay for that medicine until someone explains why you need it. So the office fills out a form, attaches your records, and sends it to the plan for review. That is prior authorization.
The part nobody describes is that this creates three separate waits, and they are invisible to each other. There is the wait for the office to prepare and send the request. There is the wait while the plan reviews it. And there is the wait for somebody to notice a decision came back. You experience all three as one long silence.
The clock exists. It starts somewhere you cannot see.
Most health plans operate under a turnaround requirement for prior authorization, and many states set one in law as well. The specific limit depends on your plan type, your state, and whether the request is standard or expedited. What matters more than the number is where the clock starts. It starts when the plan receives a complete request.
That is why “we sent it” is not the same as “the clock is running.” A request that is missing a chart note, a lab value or a signature can sit as incomplete without ever starting the timer, and nobody is obliged to tell you that is what happened.
What to ask, and who to ask
Two phone calls settle almost every case. One to the prescriber’s office, one to the plan, and they ask for different things.
Ask the prescriber’s office: on what date was the prior authorization submitted, and is there a reference or tracking number for it. If they cannot produce a date, it may not have gone out. That is worth knowing on day three rather than day thirty.
Ask your plan: what is the decision deadline that applies to this request, and is the request complete. Those are two different questions and you want both answered.
Ask either one: does an expedited review apply to my situation. Expedited timelines are much shorter and usually turn on whether waiting would put your health at risk. Your prescriber is the one who can make that case.
Write down who you spoke to and when. A named person and a date changes the next conversation more than any amount of frustration does.
If it comes back denied
A denial is a document, not a verdict. Ask for it in writing, because the written denial has to name the reason and the appeal route, and those two things are what your prescriber needs in order to respond. A large share of denials are overturned on appeal, and many are overturned on the first one.
Ask your prescriber’s office whether a peer to peer review is available. That is a direct conversation between your prescriber and a clinician at the plan, and it often resolves in one call what a paper appeal takes weeks to do.
Why this exit exists at all
Authorization sits sixth in the 10 Exits of Therapy™ because of where it falls. You have a diagnosis, a prescriber, a prescription and coverage. Everything upstream worked. And then the process stops inside a review that has no visible owner, and a meaningful number of people stop with it.
Nobody decided you should not have the medicine. The wait simply outlasted the effort it was worth. That is what makes this exit different from a denial, and it is why the dates matter so much.
Authorization is exit 6 of ten. If your treatment stalled somewhere else, find which one at Where did your treatment stop? Exit 5 is coverage. Exit 7 is affordability. Everything written for patients is gathered on the For Patients page. Terms used here are defined in the glossary.
This is navigation help, not medical advice. It does not replace anything your prescriber or pharmacist tells you, and decisions about diagnosis and treatment belong with your licensed clinician. Who pays for this work is set out in the disclosure.
Free by email
The 10 Exits of Therapy™, in your inbox
Where therapy breaks down between the prescription and the patient, in plain language.
Subscribe on Substack