What is prior authorization?
Prior authorization (PA) means the carrier must approve certain care before it happens. A PA denial is different from a claim denial after care was provided.
Overview for any state: Prior authorizations. This page is Florida-only.
Confirm plan type: Florida: Start Here.
Florida PA rules
Florida's main commercial PA statute is F.S. § 627.42392:
- If a health insurer (or PBM) does not offer electronic PA to contracted providers, it must use the state-approved two-page PA form with required clinical documentation
- The Financial Services Commission, with AHCA, adopts uniform form guidelines by rule
- Electronic PA approval does not stop later medical or pharmacy benefit review
Florida does not currently have a comprehensive state law setting 5-day PA deadlines and deemed-approval penalties like Colorado or Delaware. HMO utilization review has separate grievance rules under F.S. § 641.511.
ACA & federal UR timelines
For non-grandfathered individual and group health plans, federal rules under 45 C.F.R. § 147.136 still apply, including:
- Non-urgent: often within 15 calendar days (extendable with notice)
- Urgent: as soon as needed, considering medical exigencies—often within 72 hours
- Written notice with clinical rationale and appeal rights when PA is denied
Always follow the timeline on your specific denial or EOB.
Where to look up PA rules
Match tools to the exact plan on the ID card:
- Florida Blue: floridablue.com
- UnitedHealthcare / Oscar / Molina / Ambetter: use the member portal on your card
Florida Medicaid
Medicaid PA follows MCO and AHCA rules. Service denials: MCO grievance, then state fair hearing—see your MCO member handbook and ahca.myflorida.com.
If PA is denied
- Get the denial in writing with clinical reasons and appeal instructions.
- Ask the treating clinician for records and a medical-necessity letter.
- File an internal appeal—deadlines are on your notice (often 180 days under federal rules)— Florida internal appeals.
- For HMO plans, you may have 30 days to request internal panel review after a final adverse determination.
- If care cannot wait, request expedited review.
Building a strong appeal packet has a checklist.