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. Virginia-only details below.
Confirm plan type: Virginia: Start Here.
Virginia PA rules
Virginia regulates PA primarily through contract requirements in Title 38.2, Chapter 34. These rules generally apply to carrier contracts with participating providers for many fully insured commercial plans—not Medicare, Medicaid, TRICARE, or typical large self-funded ERISA plans.
Prescription drug PA (§ 38.2-3407.15:2)
Carrier provider contracts must require timely decisions on drug PA (§ 38.2-3407.15:2):
- Urgent drug PA: approve, deny, or request supplementation within 24 hours (including weekends) when submitted telephonically or by a carrier-directed alternate method
- Standard drug PA: decision within 2 business days of a fully completed request
- After supplementation: decision within 2 business days of properly completed supplemental information
- Electronic PA: carriers must maintain an online ePA process linking to e-prescribing/EHR systems by July 1, 2025
- Continuity: honor prior carrier PA for 90 days when switching plans; honor stable mental health and certain other authorizations per statute
- Public lists: formularies, PA-required drugs, procedures, and forms on one carrier website location, updated within 7 days of changes
Medical services PA (§ 38.2-3407.15:8, effective January 1, 2027)
New requirements for health care services (not drugs) take effect January 1, 2027, including 72-hour expedited and 7 calendar-day standard decision timeframes and a publicly posted list of services requiring PA (§ 38.2-3407.15:8). Until then, check your plan's utilization review notices and federal timing rules.
Step therapy (§ 38.2-3407.9:05)
Carriers must provide a clear exception process for step therapy overrides. Grants must follow when clinical justification supports bypassing the protocol (§ 38.2-3407.9:05).
Transparency & metrics (§ 38.2-3407.15:8)
Beginning January 1, 2027, carriers must publish annual prior authorization metrics for medical services (approval/denial rates, timeliness, and related CMS-aligned data) on their websites by March 31 each year.
Federal deadlines (some plans)
Federally regulated plans may also follow CMS timing under the 2024 Prior Authorization Rule: 72 hours urgent / 7 calendar days standard for many impacted payers—check your plan documents.
Virginia has not enacted a statewide gold-carding law for medical PA as of 2026.
Where to look up PA rules
Check your plan materials and the carrier's provider or member portal first. Carriers must post PA lists and forms in a central website location.
Carrier links: Virginia prior auth & internal appeals links.
Medicaid
Virginia Medicaid (Cardinal Care managed care) uses separate utilization management and MCO appeal rules through DMAS—not commercial § 38.2-3407.15:2 drug PA contract deadlines for most member benefit disputes.
If PA is denied
Appeal through your plan's internal grievance process, then SCC external review if needed.
Next: Virginia internal appeals.
Urgent care
Emergency care cannot require prior authorization. For urgent prescription drug PA, Virginia requires a carrier response within 24 hours when submitted by phone or a carrier-directed urgent channel. For urgent medical necessity disputes after a denial, request expedited internal appeal and may qualify for expedited external review (including some cancer-treatment denials before exhausting internal appeal—see SCC guidance).