What is prior authorization?
Prior authorization (PA) means the health plan must approve certain care before it will cover it. Providers often submit requests for you, but you still have rights if PA is denied or delayed.
Overview: Prior authorizations. New Jersey-only details below.
Confirm plan type: New Jersey: Start Here.
New Jersey PA rules
The Prior Authorization Transparency Act (ETPAA) took effect in 2023 as P.L. 2023, c.296, codified at N.J.S.A. 17B:30-55. These rules apply to most fully insured health benefits plans in New Jersey—not Medicare, Medicaid fee-for-service, or typical self-funded ERISA plans.
Prescription drugs (N.J.S.A. 17B:30-55.6)
- Urgent ePA: carrier responds within 24 hours after obtaining necessary information
- Non-urgent ePA: within 72 hours
- Beginning January 1, 2027, carriers must accept pharmacy PA only through secure electronic NCPDP SCRIPT ePA
Medical services (N.J.S.A. 17B:30-55.11)
- Outpatient / other settings: denial or limitation communicated within 9 calendar days (electronic portal) or 12 days (paper) after the request
- Current inpatient or ED: within 24 hours, as medically appropriate
- Urgent care claims: benefit determination within 72 hours of receipt; if more information is needed, carrier must ask within 24 hours and decide within 48 hours after receiving it
- If the payer misses applicable deadlines, the service is generally not denied for lack of PA (17B:30-55.11(d)); broader automatic authorization may also apply (17B:30-55.15)
- If the provider fails to respond to a payer's request for more information within 72 hours, the PA request may be deemed withdrawn
Other protections
- Chronic or long-term care PA remains valid 180 days unless safety monitoring requires shorter periods (17B:30-55.7)
- New payer must honor prior PA from a previous payer for 60 days after coverage starts when documentation is provided (17B:30-55.10)
- PA denials must be made by a physician following published medical policies (17B:30-55.8–55.9)
- 90-day notice before new materially adverse PA requirements for contracted providers (17B:30-55.4)
DOBI bulletin on implementation: Bulletin blt24_17.
Where to look up PA rules
Carriers must publish PA criteria. Use your denial letter first, then your plan's provider or member portal.
Carrier links: New Jersey prior auth & internal appeals links.
Medicaid
ETPAA does not apply to Medicaid fee-for-service, but NJ FamilyCare managed care plans follow federal PA rules and MCO timeliness requirements. Denials use MCO grievance and fair hearing paths—see New Jersey internal appeals.
If PA is denied
File an internal UM appeal with the carrier within 180 days of the adverse determination for most commercial plans (DOBI UM appeals Q&A).
Next: New Jersey internal appeals.
Urgent care
Mark requests urgent when delay would seriously jeopardize life, health, or ability to regain maximum function (prudent layperson standard under 17B:30-55.3). Urgent PA and claim deadlines are much shorter than non-urgent timelines above.
Expedited internal appeals must be decided within 72 hours when the case is urgent.