Effective Nov. 1, 2026, prior authorization must be obtained before services are rendered for all services that require authorization. Retrospective authorization requests – requests submitted after services have already been provided – will only be considered in limited, exception-based situations.
This change is intended to support timely authorization review before services are rendered, helping ensure coverage requirements are met before care delivery and reducing administrative rework after services have been provided.
This change impacts all plans (Medicare, Medicaid and commercial) across medical / surgical services, outpatient services, lab tests and drug authorizations. (Note: This change doesn't apply to behavioral health or durable medical equipment (DME) authorization processes.)
Limited exceptions
Today, retrospective authorization requests may be reviewed in a broader range of circumstances. Effective Nov. 1, retrospective authorization requests may only be considered on a case-by-case basis in limited circumstances, including:
- Urgent / emergent care
- Coverage can’t be identified at the time of service
- Administrative or technical errors
- Continuity of care
- Changes post-procedure to the original codes requested
To avoid disruptions, we recommend you:
- Verify prior authorization requirements prior to scheduling services
- Submit prior authorization requests as soon as possible but at least 7 days before the service date
- Confirm member eligibility at the time of service
Claim denials
Claims received for services requiring prior authorization that are rendered when no authorization is on file are denied to provider liability (you may not bill the member). Beginning Nov. 1, these claims won’t generally be reviewed for medical necessity unless one of the exception criteria described above applies.
Claim disputes
If your claim is denied for no authorization and you believe the exception criteria apply, you may submit a claim dispute with appropriate documentation for consideration.
Note: A contracted provider can’t appeal on behalf of a Priority Health Medicare member. The member has the right to appeal a denial. See Reconsideration/appeals under Medicare for more information.
More information
Get more information about this change in our FAQ.