Most clients do not know their ACA plan requires prior authorization for an MRI until the imaging center tells them on the day of the appointment. By that point, the broker is already getting the call, and the client already has a scheduling conflict and a growing anxiety about a bill they thought was covered.
Key Takeaways
- ACA Marketplace plans are permitted to require prior authorization for covered services. The plan determines which services require it. The same service, such as an MRI or a specialist visit, may require prior auth on one plan in a rating area and not another.
- Federal regulations (45 CFR 147.136 implementing PHSA 2719) set mandatory timelines. Urgent requests must receive a decision within 72 hours. Non-urgent pre-service requests must be decided within 15 calendar days, with a one-time 15-day extension permitted if the plan requests additional clinical information.
- Every ACA-compliant plan must provide internal and external appeal rights for prior auth denials. External review is conducted by an independent review organization not affiliated with the plan. The plan cannot block or delay the external review process.
- The Summary of Benefits and Coverage discloses that prior authorization may be required but typically does not list every affected service. The Evidence of Coverage or plan document contains the full list. Brokers who rely on the SBC alone often miss service-specific requirements.
- Step therapy protocols require enrollees to try a clinically equivalent lower-cost drug before the plan will approve the prescribed one. Plans must have an exception process, but the standard varies. Exception approvals are not guaranteed and often require clinical documentation from the treating physician.
What prior authorization is and is not
Prior authorization is a utilization management tool. The plan requires the treating provider to obtain clinical approval before delivering a covered service. If the plan approves, the service is covered subject to normal cost sharing. If the plan denies, the service is not covered under that request. The enrollee can still receive care and pay out of pocket, or the provider can resubmit with additional documentation, or the denial can be appealed.
Prior authorization is not a guarantee that a claim will be paid. Plans can subsequently deny a claim even when PA was granted, typically because the service delivered was different from what was authorized, the provider was out of network, or the clinical criteria were not met at the time of care. PA reduces the risk of a claim denial for the authorized service. It does not eliminate it.
PA is also not universal. The same service may require prior auth on a Silver HMO plan from one carrier and not on a Silver PPO from a different carrier in the same rating area. Plan-level variation is the rule, not the exception. Tools like Connecture display plan summary data and benefit comparison grids, but the full PA service list is in the Evidence of Coverage, not the comparison view. Brokers who rely on the summary alone miss plan-specific requirements that matter most for high-utilizing clients.
Services that commonly require prior authorization
The table below shows service categories where prior auth is a common or near-universal requirement on ACA Marketplace plans. Specific plans vary. Confirm at the plan level before advising a client that a service is pre-authorized.
| Service category | PA frequency | Broker note |
|---|---|---|
| Elective inpatient admissions | Almost always required | Notification often required within 24 to 48 hours even for emergency admissions that convert to inpatient |
| Non-emergency outpatient surgery | Commonly required | Facility authorization and surgeon authorization may be separate requirements on some plans |
| Advanced imaging (MRI, CT, PET) | Commonly required | Among the most frequently denied categories; radiology benefit management companies often handle this separately |
| Specialty drugs (Tier 4 and 5) | Almost always required | Step therapy and quantity limits add separate hurdles beyond PA; formulary check is the first step |
| Physical, occupational, speech therapy | Varies by plan | Plans may set visit limits or require PA after a threshold (e.g., after 12 visits per plan year) |
| Primary care and specialist visits | Rarely required on PPO and EPO; common on some HMOs | HMO referral requirements are distinct from PA but functionally similar for specialist access |
| Durable medical equipment | Commonly required for higher-cost items | CPAP machines, wheelchairs, and prosthetics commonly trigger PA; rental vs. purchase distinctions add complexity |
Service categories are illustrative. PA requirements vary by plan, carrier, and plan year. Confirm in the plan Evidence of Coverage before advising a client.
For clients on multiple specialty medications, the formulary and drug tier structure matters as much as the PA list. A drug may be on formulary but still require PA or step therapy before the plan approves the prescribed dose or brand. For a detailed walkthrough of formulary checks before enrollment, read ACA formulary and drug tiers: a broker checklist before recommending a plan.
Timeline requirements under ACA regulations
Federal regulations implementing PHSA 2719 (codified at ) set mandatory response timelines for ACA plan utilization review decisions. Plans must adhere to these regardless of their internal administrative processes.
For urgent care situations where waiting for the standard timeline would seriously jeopardize the enrollee's health or ability to regain maximum function, the plan must provide a PA decision within 72 hours of receiving the request. For non-urgent pre-service requests, the plan must decide within 15 calendar days. The plan may extend this by 15 days if additional clinical information is needed, but must notify the enrollee of the extension within the original 15-day window and specify what information is needed. A plan cannot simply hold a request indefinitely.
For concurrent care reviews (a service already in progress that the plan decides to terminate or reduce), notification must give the enrollee sufficient time to appeal before the service stops. Retroactive termination of an in-progress course of treatment is a separate category with additional protections.
The PA checklist at enrollment
The enrollment call is the right moment to surface PA requirements for high-utilizing clients. The conversation is short and specific, not a general warning. Three steps:
First, identify the two or three services the client uses most consistently: specialist visits, a specific medication, imaging, physical therapy. These are the services that will generate PA requests if they require authorization.
Second, check whether the treating provider is in-network. A PA denial for an out-of-network provider is different from a clinical denial and the remedy is different. Network type matters here. An HMO requires a primary care referral for specialists, which is a gatekeeping function similar to PA but governed by different rules. For a breakdown of how HMO, PPO, EPO, and POS networks differ on the Marketplace, read ACA network types explained.
Third, confirm the plan's internal appeals contact and timeline. Clients who have never appealed a PA denial before need to know this process exists and is not complicated to initiate.
What to do when a client gets a PA denial
A denial letter is required under federal regulations and must include the specific clinical reason for the denial, the criteria used to make the determination, and information about how to appeal. The letter is the starting document for the appeal.
The internal appeal must be filed first. For urgent denials, the internal appeal decision must be issued within 72 hours. For non-urgent pre-service denials, within 30 days. If the internal appeal fails, external review through an independent review organization (IRO) is available. The external review decision is binding on the plan. The enrollee has up to four months from the initial adverse benefit determination to request external review.
The treating physician's documentation is the most important input to both levels of appeal. Generic letters are less effective than letters that address the plan's specific denial criteria and explain why those criteria are met. Brokers who facilitate the connection between the client and the treating physician's office at this stage provide concrete value that retention numbers track.
FAQ
Common questions brokers field when clients encounter prior authorization requirements.
Can a plan deny prior authorization for a service the doctor says is medically necessary?
Yes. Plans make PA determinations based on their own clinical criteria, which may differ from the treating physician's judgment. A denial means the plan will not cover the service under the current request, not that the service is unavailable. The enrollee can still receive the care and pay out of pocket, or the denial can be appealed. The appeals process is the correct path when the treating physician believes the service is medically necessary and can provide clinical documentation to support that determination. External review through an independent review organization is available if the internal appeal fails and is binding on the plan.
What is the difference between a prior authorization denial and a claim denial?
A prior authorization denial occurs before care is delivered: the plan has reviewed the request and declined to pre-approve coverage. A claim denial occurs after care is delivered: the plan has received the bill and declined to pay it. Both trigger appeal rights, but the timing and practical impact differ. A PA denial gives the enrollee information before incurring the cost. A claim denial arrives after the cost has already been incurred. For high-cost services, getting PA before treatment is substantially preferable to appealing after the fact, even though both processes are available.
Does the No Surprises Act affect prior authorization?
The No Surprises Act primarily addresses balance billing protections for emergency care and non-emergency care at in-network facilities from out-of-network providers. It does not eliminate prior authorization requirements. However, it did introduce some related protections: plans must provide good-faith cost estimates upon request, and CMS issued guidance on transparency around PA requirements. A separate 2024 CMS rule on prior authorization transparency requires certain payers to provide PA decisions within specific timeframes and to make PA information available through electronic APIs, with implementation timelines varying by payer type. ACA QHP issuers on the FFM are subject to specific implementation dates under that rule.
What should a broker tell a client with a chronic condition before enrollment?
Three things at minimum: first, identify the two or three services or medications the client uses most regularly and check whether those specific services require prior auth on the plan being considered. This means reading the Evidence of Coverage, not just the SBC. Second, confirm the prescribing physician or specialist is in-network. A prior auth denial due to an out-of-network provider is a different problem than a clinical denial. Third, note the plan's internal appeal timeline and external review process, so the client understands their options if a denial occurs. Clients who know the appeals process before they need it handle denials differently than clients who encounter the process for the first time while already under financial or clinical stress.
Is step therapy the same as prior authorization?
No, though they often appear together for specialty medications. Step therapy is a protocol requiring an enrollee to try one or more alternative drugs before the plan will authorize the originally prescribed medication. Prior authorization is a broader approval process that can apply to any covered service, not just drugs. A specialty drug may require both: PA approval to cover it at all, plus completion of step therapy to demonstrate the lower-cost alternatives were tried first. Exception requests for step therapy failures require documentation from the treating physician. Most states have enacted step therapy exception laws requiring plans to have an exception process, but the standard for granting an exception varies.
Competitor data verified: June 2026. Vendors update features and pricing without notice — confirm directly before purchasing decisions. Connecture is a trademark of its respective owner. QualityQuotes is not affiliated with or endorsed by Connecture.
