What is prior authorization?
Prior authorization (PA)—also called preauthorization—means the health plan must approve certain care beforeit will cover it. Doctors or hospitals often submit PA on the patient's behalf, but the patient still has rights if PA is denied.
A PA denial is different from receiving a bill denial after care already happened. With PA, the fight is usually about whether the plan will allow the treatment at all.
Overview for any state: Prior authorizations. This page is Illinois-only.
Confirm plan type: Illinois: Start Here.
Illinois PA rules (215 ILCS 200)
The Prior Authorization Reform Act (Public Act 102-0409, effective January 1, 2022) is codified as 215 ILCS 200. It applies to many health insurance issuers and their utilization review organizations regulated by IDOI—not to every plan (for example, self-funded ERISA plans are generally excluded unless they opt in).
Non-urgent services
- The issuer or its review organization must approve or deny and notify the patient, doctor, and provider within 5 calendar days after obtaining all necessary information (215 ILCS 200/25).
- "Necessary information" can include a face-to-face evaluation, a second opinion, or other clinical records the plan requires—so track when records were sent, not just when the doctor first asked.
Urgent services
- Decision and notice within 48 hours after the plan has all information needed to review the request (215 ILCS 200/30).
- Plans must give clinicians access to trained staff (with physician backup) for urgent PA questions.
If the plan misses deadlines
Failure to meet PA deadlines and other Act requirements can result in services being automatically deemed authorized (215 ILCS 200/75). Keep dated proof of submission and every plan response.
How long approvals last
- Acute conditions: often valid for the lesser of 6 months, length of treatment, or plan renewal (215 ILCS 200/60)
- Chronic or long-term conditions: often the lesser of 12 months or length of treatment
PA denials must be explained
When PA is denied, the plan must tell the patient and doctor the reasons, the evidence-based criteria used, how to appeal, and what extra documentation could help (215 ILCS 200). Denials should be reviewed by an Illinois-licensed physician in a comparable specialty.
Prescription drug PA
Illinois has additional pharmacy rules under the Managed Care Reform Act:
- Standard Rx PA form: approve or deny within 72 hours of receipt; 24 hours for expedited (215 ILCS 134/45.2)
- Formulary exceptions: often 72 hours standard, 24 hours expedited (215 ILCS 134/45.1)
Medicaid and Medicare drug rules follow separate programs.
Where to look up PA rules
PA is handled by the issuer on the ID card. Common Illinois Marketplace and commercial carriers:
- Blue Cross Blue Shield of Illinois: bcbsil.com
- Health Alliance: healthalliance.org
- Molina Healthcare: molinahealthcare.com
- Ambetter / Celtic: ambetterhealth.com
Issuers must post current PA requirements on their websites under 215 ILCS 200.
Illinois Medicaid
Medicaid PA and appeals follow MCO and HFS rules, not only 215 ILCS 200. Service denials: plan grievance, then fair hearing—see HFS — appeals.
If PA is denied
- Get the denial in writing with reasons and appeal instructions.
- Ask the treating clinician for records and a medical-necessity letter.
- File an internal appeal by the deadline— Illinois internal appeals.
- If still denied, consider external review through IDOI for eligible plans.
Building a strong appeal packet has a checklist.
Urgent care
Use the 48-hour urgent PA rule. Emergency services generally cannot require PA first under Illinois managed care rules. For urgent denials, internal appeals may need a decision within 24 hours after the plan has required information (215 ILCS 134/45(b)). See Illinois external review for concurrent expedited external review.