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. Pennsylvania-only details below.
Confirm plan type: Pennsylvania: Start Here.
Pennsylvania PA rules
Act 146 of 2022 (Senate Bill 225) amended the Insurance Company Law of 1921, effective January 1, 2024, for most fully insured commercial health plans regulated by PID. Key provisions are in 40 P.S. § 991.2155 (Act 146). These rules generally do not apply to Medicare, typical self-funded ERISA plans, or many federal programs.
Standard PA deadlines (§ 991.2155)
- Urgent service not yet started: as soon as possible, but not more than 72 hours
- Ongoing urgent service (request at least 24 hours before reduction/termination): within 24 hours
- Non-urgent requests: within 15 days (may extend if missing information was timely requested; insurer may allow up to 45 additional days for provider response)
- Prescription drug / step therapy — urgent: within 24 hours
- Prescription drug / step therapy — non-urgent: within 2 business days, not more than 72 hours
Transparency & electronic submission
- Insurers must publish PA lists, criteria, and use electronic PA submission networks
- Written denial must include specific reasons and appeal instructions
- 30-day advance notice before new PA requirements take effect
Who can deny
Non-administrative denials must be made by a licensed health care provider in the same or similar specialty that typically manages the service (§ 991.2155(d)–(e)). Peer-to-peer reviewers must meet the same standard.
When PA is prohibited or limited
- Emergency services — no prior authorization (consistent with federal No Surprises Act)
- Minimum requirements for FDA-approved medication-assisted treatment for opioid use disorder without PA
Missed deadlines
Unlike some states, the enacted version of Act 146 does notinclude automatic "deemed approved" treatment when an insurer misses a PA deadline. If a plan is late, document the delay and contact PID at 877-881-6388 or file a complaint.
Where to look up PA rules
Insurers must disclose PA requirements on their websites. Check your plan materials and the carrier portal first.
Carrier links: Pennsylvania prior auth & internal appeals links.
Medicaid
Medicaid and CHIP managed care plans follow Act 146 PA timing in 40 P.S. § 991.2155 and separate managed care rules. Denials use MCO grievance/complaint and fair hearing paths—see Pennsylvania internal appeals.
If PA is denied
Appeal the adverse benefit determination using your plan's internal process under Act 146 § 2164, then external review if needed.
Urgent care
Mark requests urgent when delay would seriously jeopardize life, health, or ability to regain maximum function. Insurers must meet the 72-hour, 24-hour, or 24-hour drug timelines above.
You may request expedited internal and external appeals in qualifying urgent situations under Act 146 § 2164.6.