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. Vermont-only details below.
Confirm plan type: Vermont: Start Here.
Vermont PA rules
Vermont's core PA statute is 18 V.S.A. § 9418b, substantially strengthened by Act 111 (H.766, 2024, effective January 1, 2025). Act 111 applies broadly to health plans regulated under Vermont law, including many Vermont Health Connect and fully insured commercial plans—not Medicare or typical large self-funded ERISA plans.
Response deadlines (§ 9418b(g)(4))
- Acknowledgment: within 24 hours of receipt; notify if information is missing
- Urgent PA: approve, deny, or request missing information within 24 hours; if more info is requested, decide within 24 hours after it is received
- Non-urgent PA: approve or deny within 2 business days of a complete request
- Deemed granted: if the plan misses these deadlines for response, acknowledgment, or a timely request for missing information
Other Act 111 protections
- No PA for primary care orders: plans may not require PA for admissions, items, services, treatments, or procedures ordered by a primary care provider (DFR encourages extending this to all enrolled PCPs)
- Authorization duration: PA valid for the treatment period or 1 year, whichever is longer (certain services may renew at most every 5 years)
- Plan switch continuity: at least 90 days of continued stable medication or treatment when changing plans
- 30-day advance notice before modifying PA requirements (existing law)
- Annual review to eliminate PA requirements that are no longer justified (§ 9418b(h))
- Step therapy overrides: 8 V.S.A. § 4089i — same timelines as PA; deemed override on missed deadlines
DFR FAQ: Act 111 Implementation FAQ
Federal deadlines (some plans)
Federally regulated plans may also follow CMS timing: 72 hours urgent / 7 calendar days standard—check your plan documents.
Where to look up PA rules
Check your plan materials and the carrier's provider or member portal first.
Carrier links: Vermont prior auth & internal appeals links.
Medicaid
Vermont Medicaid (Green Mountain Care) uses separate utilization management and appeal rules through DVHA—not commercial Act 111 PA deadlines for most member benefit disputes.
If PA is denied
Appeal through your plan's internal grievance process, then independent external review with DFR if needed.
Next: Vermont internal appeals.
Urgent care
Emergency care cannot require prior authorization. For urgent PA, Vermont law requires a decision within 24 hours after receipt (or after supplemental information is received). Pharmacy, mental health, and cancer-related requests are often treated as urgent under DFR utilization review rules unless the provider says otherwise.