What is prior authorization?
Prior authorization (PA)—part of utilization review—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.
Overview for any state: Prior authorizations. This page is Missouri-only.
Confirm plan type: Missouri: Start Here.
Missouri PA rules
Missouri's utilization review and PA standards are primarily in RSMo § 376.1363, § 376.1364, and § 376.1372. These apply to many fully insured Missouri health carriers; self-funded ERISA plans are generally excluded.
Prospective (pre-service) review
- Decision within 36 hours, which must include one working day, after the carrier has all necessary information (§ 376.1363.2)
- Adverse determination: notify the provider within 24 hours by phone or electronically; written confirmation to enrollee and provider within one working day (§ 376.1363.2(2))
- Written adverse determination must include clinical rationale, criteria, and appeal instructions (§ 376.1363.5)
Concurrent review (ongoing care)
- Decision within one working day of obtaining necessary information (§ 376.1363.3)
- If denied, service continues without enrollee liability until the enrollee is notified (§ 376.1363.3(2))
Retrospective review
- Decision within 30 working days; written notice to enrollee within 10 working days of the determination (§ 376.1363.4)
Electronic PA and transparency
- Unique confirmation number for every PA request (§ 376.1364.1)
- Electronic PA for drugs (NCPDP SCRIPT) and other services required since January 1, 2021 (§ 376.1364.2–3)
- Current PA requirements and clinical criteria must be on the carrier's website or provider portal; new requirements need 60 days advance notice to in-network providers (§ 376.1372)
Protections after approval
- PA generally cannot be revoked within 45 working days of the provider receiving it (§ 376.1363.7)
- Carriers cannot bill enrollees for services that had valid PA at the time of service (except applicable cost-sharing) ( § 376.1363.8)
Federal CMS prior-authorization rules (7 calendar days standard / 72 hours urgent) also apply to many Marketplace, Medicare Advantage, and Medicaid managed care plans starting in 2026.
Where to look up PA rules
Missouri law requires carriers to post PA lists and criteria online. Start with your denial letter, then check your carrier's provider portal.
Carrier links: Missouri prior auth & internal appeals links.
DCI publishes a map of individual-market carriers by county: insurance.mo.gov — health rate map.
MO HealthNet
MO HealthNet managed care (Healthy Blue, Home State Health, UnitedHealthcare Community Plan, and others) follows MCO prior authorization rules under federal Medicaid law in addition to Missouri utilization review statutes where applicable.
Service denials use MCO appeal and state fair hearing paths—see Missouri internal appeals.
If PA is denied
- Read the denial for clinical rationale, criteria, and appeal instructions.
- Ask the treating clinician for records and a letter of medical necessity.
- File an internal appeal with the plan using the process in your notice.
- If internal appeal fails, contact DCI about external review.
Next: Missouri internal appeals.
Urgent care
For ongoing or time-sensitive care, concurrent review rules require faster decisions and continued coverage during appeal of an adverse determination (§ 376.1363.3). Ask the provider to flag urgency and document why delay would harm the patient.
You may also qualify for expedited internal appeal and expedited external review under federal standards when life or health is at serious risk.