What is prior authorization?
Prior authorization (PA)—also called preauthorization—means the health plan must approve certain care before it will cover it. Doctors or hospitals often submit PA for you, but you still have rights if PA is denied.
A PA denial is different from 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 Maryland-only.
Confirm plan type: Maryland: Start Here.
Maryland PA rules
Maryland regulates utilization review and prior authorization through Insurance Article § 15-10B (private review agents) and related provisions, including § 15-1009 (payment for preauthorized care).
Non-emergency prior authorization
- Initial determination on non-emergency treatment (including non-electronic pharmacy) often within 2 working days after the reviewer receives information needed to decide (§ 15-10B-05)
- Electronic pharmacy PA: often real time or within 1 working day after complete information
- If more information is needed, the reviewer must request it promptly—generally within 3 calendar days
Emergency and behavioral health
- Emergency services: determination often within 24 hours after necessary information is received
- Emergency inpatient mental health or substance use admission: often within 2 hours
- Certain involuntary or imminent-danger hospital admissions: restrictions on adverse decisions during initial 24–72 hours when hospitals notify the reviewer promptly (§ 15-10B-06)
After PA is approved
Under § 15-1009, if a service was preauthorized or approved, the carrier generally may not deny reimbursement to the provider except in limited cases (for example, material change in treatment plan, patient not covered on date of service, or fraud).
Prescription drugs
Maryland has additional pharmacy PA reforms (step therapy exceptions, honoring certain prior authorizations when changing plans, notice before new PA requirements). Carriers must publish PA standards and accept electronic PA where required.
Where to look up PA rules
Each carrier publishes PA criteria and submission methods. Use the links on Maryland: prior auth & internal appeals links or call the number on the member ID card.
Marketplace plans are sold through Maryland Health Connection; major carriers include CareFirst, Kaiser Permanente, UnitedHealthcare, and Wellpoint.
HealthChoice / Medicaid
HealthChoice MCOs have separate authorization and appeal rules under Maryland Medicaid regulations. Service denials: appeal with your MCO first—see MDH — Medicaid appeal and Maryland internal appeals.
If PA is denied
A PA denial is usually an adverse decision. The carrier must notify you with grievance rights (§ 15-10A-02).
Next: Maryland internal appeals → Maryland external review (MIA).
Urgent care
Ask the provider to request expedited review when delay could seriously harm health. Maryland allows filing an MIA complaint without completing internal grievance in some urgent medical circumstances when care has not yet been rendered (§ 15-10A-03(b)). The HEAU can help you decide next steps.