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. Rhode Island-only details below.
Confirm plan type: Rhode Island: Start Here.
Rhode Island PA rules
Rhode Island's Benefit Determination and Utilization Review Act is codified at R.I. Gen. Laws §§ 27-18.9-1 et seq., with detailed standards in OHIC regulations (230-RICR-20-30-14). These laws generally do not apply to Medicare, typical self-funded ERISA plans, or many federal programs.
Standard PA deadlines
- Urgent or emergent services: determination within 72 hours of receipt (§ 27-18.9; regulations at 230-RICR-20-30-14.6)
- Concurrent review: often within 24 hours when care is already in progress
- Non-urgent pre-service requests: within 15 calendar days
- Post-service retrospective review: within 30 calendar days in many cases
Primary care PA pilot (2025–2028)
The Rhode Island Prior Authorization Reform Act of 2025 (H 5120 / § 27-18.9-16) runs a three-year pilot from October 1, 2025 through October 1, 2028. During the pilot, insurers generally may not require PA for admissions, items, services, treatments, or procedures ordered by an in-network primary care provider in the normal course of primary care. The prohibition does not apply to prescription drugs.
Who can deny and transparency
- Insurers must provide clinical criteria upon request
- Appeal reviewers must be appropriately qualified and, for non-administrative appeals, must have direct communication with the patient's treating provider before upholding a denial
- Limited retroactive denial when authorization was obtained and care matched the approved plan
Missed deadlines
Rhode Island law does not automatically treat late PA decisions as approved. Document delays and contact OHIC or RIREACH at 855-747-3224.
Where to look up PA rules
Check your plan materials and the carrier's provider or member portal first.
Carrier links: Rhode Island prior auth & internal appeals links.
Medicaid
Medicaid managed care follows federal utilization management rules and EOHHS oversight. The primary-care PA pilot also applies to Medicaid plans under related state law. Denials use MCO appeal and fair hearing paths—see Rhode Island internal appeals.
If PA is denied
Appeal the adverse benefit determination using your plan's internal process under Chapter 27-18.9.
Urgent care
Mark requests urgent when delay would seriously jeopardize life, health, or ability to regain maximum function. The plan must decide within 72 hours for urgent PA under Rhode Island law.
You may request expedited internal and external appeals in qualifying urgent situations.