What is prior authorization?
Prior authorization (PA)—sometimes called preauthorization—means your insurer must agree that a service is medically appropriate before you receive it (or before it will pay). This is common for expensive imaging, specialty drugs, surgeries, and some mental health services.
A PA denial is different from a bill denial after you already had care. With PA, the fight is usually about whether the plan will allow the service at all.
Overview for any state: Prior authorizations. This page is Idaho-only.
Confirm plan type first: Idaho: Start Here.
Idaho PA rules
Idaho does not yet have a broad "PA reform" law like some states (with 5-day deadlines and automatic approval if the plan is late). The main state rule many advocates cite is in the Managed Care Reform chapter:
Non-emergency PA
- Managed care organizations must respond within 2 business days after they receive complete medical information for the request.
- "Complete" matters—the clock often does not start until the doctor sends everything the plan asked for. Keep dates of submission and any "we need more information" letters.
- The plan may allow a longer period only in exceptional circumstances (the statute does not define every example—document what the plan tells you).
Emergency services
Plans cannot require prior authorization for emergency servicesunder § 41-3930. If someone was seen in an emergency, a later denial citing "no PA" may be worth challenging.
After PA is approved
If PA was granted and the member received the covered service, the approval is generally final. The plan usually cannot take it back afterward except in narrow cases (fraud, misrepresentation, premium not paid, benefits used up, or member not enrolled when care happened).
Who must follow § 41-3930?
This section applies to managed care organizations doing utilization management in Idaho. Many Idaho commercial and Medicaid managed care plans fall here, but always match rules to the plan type on the card.
Federal rules on Marketplace plans
Plans sold through Your Health Idaho are still subject to federal Affordable Care Act rules for many utilization review timelines. Non-grandfathered plans often must decide standard PA requests within about 15 calendar days and urgent requests much faster (often within 72 hours), under 45 C.F.R. § 147.136.
When state and federal rules both apply, use whichever gives the patient more protection—and always follow the deadline printed on the patient's own denial or EOB.
Where to look up PA rules
PA is handled by the issuer on the ID card, not by Your Health Idaho itself. Common Idaho Marketplace and commercial carriers include:
- Blue Cross of Idaho: bcidaho.com
- SelectHealth: selecthealth.org
- Regence BlueShield of Idaho: regence.com/idaho
- PacificSource: pacificsource.com
Provider offices often submit PA; members can still ask the plan for status and copies of denials.
Idaho Medicaid
Idaho Medicaid uses managed care plans (for example for physical health and behavioral health). PA and appeals follow MCO rules plus Medicaid federal rules, not only § 41-3930. Service denials: appeal with the MCO first, then you may request a state fair hearing—see IDHW — appeals and fair hearings.
If PA is denied
- Get the denial in writing. It should explain the clinical reason and how to appeal (an adverse benefit determination).
- Ask the treating clinician for records and a short letter on why the service is medically necessary for this patient.
- File an internal appeal / grievance with the plan by the deadline on the letter—see Idaho internal appeals.
- If the plan upholds the denial, consider external review through DOI for eligible Idaho-regulated plans.
Building a strong appeal packet walks through documents to include.
Urgent care
If waiting for a routine PA decision would seriously harm the patient, ask the plan for an expedited (urgent) review. Federal rules and Idaho external review law both have faster tracks when delay would jeopardize life, health, or ability to function.
For urgent denials, internal grievances may need an answer within 3 business days (I.C. § 41-5907). See Idaho external review for concurrent expedited external review.