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. Ohio-only details below.
Confirm plan type: Ohio: Start Here.
Ohio PA rules
Ohio's main PA statutes (from Substitute Senate Bill 129, 2016) apply in parallel depending on plan type:
- R.C. § 3923.041 — sickness and accident insurance policies with PA requirements
- R.C. § 1751.72 — health insuring corporation (HMO) policies
- R.C. § 5160.34 — Medicaid managed care
These laws generally do not apply to Medicare, typical self-funded ERISA plans, or many federal programs. Fully insured commercial and HMO plans issued on or after the effective dates below must follow them.
Standard PA deadlines
- Urgent care services: response within 48 hours of receipt (§ 3923.041(B)(4); § 1751.72(B)(4))
- Non-urgent requests: within 10 calendar days of receipt when submitted electronically per statute
- Emergency services: PA timing rules do not apply to emergency services (same divisions)
Electronic submission & transparency
- Insurers must accept electronic PA using NCPDP SCRIPT (pharmacy) and CAQH operating rules (medical services) where applicable
- New PA requirements must be disclosed to participating practitioners at least 30 days before the effective date
How long PA lasts
- Chronic-condition drug approvals: honor PA for at least 12 months (or until coverage ends), with limited quarterly re-verification
- Insurers may terminate a 12-month approval if the practitioner does not respond within 5 calendar days to a re-verification request
Retroactive denial limits
Except for fraud or materially incorrect information, insurers generally cannot retroactively deny PA when the service was rendered consistent with an approved authorization (§ 3923.041(C); § 1751.72(C)).
Gold carding (HB 122)
Ohio requires insurers to operate gold-carding programs: providers with roughly 90%+ approval rates for a given service may be exempt from PA for that service for at least one year, subject to revocation rules. Ask your insurer whether your treating provider qualifies.
PA appeals
Adverse PA determinations must follow streamlined appeal procedures (§ 3923.041(B)(12); § 1751.72(B)(12)), with rights to external review under Chapter 3922.
Where to look up PA rules
Check your plan materials and the carrier's provider or member portal first.
Carrier links: Ohio prior auth & internal appeals links.
Medicaid
Medicaid managed care follows R.C. § 5160.34 and OAC managed care rules. Denials use MCO appeal and state fair hearing paths—see Ohio internal appeals.
If PA is denied
Appeal using your plan's adverse determination procedures and Ohio's streamlined PA appeal process.
Next: Ohio internal appeals.
Urgent care
Mark requests urgent when delay would seriously jeopardize life or health. The insurer must respond within 48 hours for urgent PA under Ohio law.
You may request expedited internal and external appeals in qualifying urgent situations under Chapter 3922.