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 York-only details below.
Confirm plan type: New York: Start Here.
New York PA rules
New York's utilization review laws in Insurance Law Article 49, § 4903 (and parallel Public Health Law § 4903 for HMOs) apply to most fully insured and state-regulated plans—not Medicare, typical self-funded ERISA plans, or federal programs.
Standard PA deadlines (§ 4903)
- Standard pre-authorization: determination by telephone and in writing within 3 business days after receipt of necessary information
- Inpatient rehabilitation following a hospital or SNF stay: within 1 business day
- Urgent / expedited: telephonic notice within 72 hours of the request; written notice within 3 business days
- If the utilization review agent misses applicable deadlines after receiving necessary information, the request is deemed approved
Step therapy overrides (§ 4903)
- Override decisions within 72 hours standard or 24 hours when urgent
- Failure to respond within statutory timeframes → override deemed approved
- Approved overrides honored for the lesser of the treatment duration in evidence-based guidelines or 12 months
- New step-therapy guardrails in § 4902 take effect for many plans January 1, 2026 (limits on fail-first requirements)
When PA is prohibited
- HIV/AIDS antiretrovirals on formulary, including PrEP: no prior authorization as of December 25, 2024 (DFS Circular Letter supplement; Insurance Law §§ 3216, 3221, 4303)
- Carriers generally cannot retroactively deny properly pre-authorized services except in limited cases (ineligibility, untimely claim, benefit exhaustion, fraud, or materially inaccurate information—see §§ 3228, 4905)
Where to look up PA rules
Your denial letter and plan materials should list PA requirements. DFS publishes consumer guidance on health insurance rights at dfs.ny.gov/consumers/health_insurance.
Carrier links: New York prior auth & internal appeals links.
Medicaid
Medicaid managed care plans follow federal and state utilization review rules, which often mirror Article 49 timelines. Denials use plan appeal, DFS external review, and fair hearing paths—see New York internal appeals.
If PA is denied
File an internal appeal within the deadline in your notice—at least 45 days under Insurance Law § 4904 (many DFS-regulated plans allow 180 days).
Next: New York internal appeals.
Urgent care
Request expedited PA and appeals when delay would seriously jeopardize life or health. Urgent PA must be decided within 72 hours (§ 4903). Expedited internal appeals must be decided within 2 business days, or 24 hours for certain inpatient substance-use disorder cases (§ 4904).
You may request simultaneous expedited internal and external appeals in qualifying urgent situations.