Does this code need prior authorization?
Type a CPT or HCPCS code, or pick a service category, and choose the payer type. You get a plain answer: whether authorization is commonly required, what the payer checks, what to send and how fast the plan has to decide. Rules differ from plan to plan, so treat this as the starting point, not the plan's policy.
Your answer appears here
Enter a code or pick a category on the left. Try one of the examples to see what a result looks like.
Checking the rules...
How fast must the plan answer in 2026?
The CMS Interoperability and Prior Authorization final rule (CMS-0057-F) set hard clocks for government programs starting January 1, 2026. Commercial employer plans follow state law and the contract instead.
Expedited means a delay could seriously harm the patient's health or ability to regain function. Say so in the request and the 72-hour clock applies.
| Payer type | Standard request | Expedited request | Notes |
|---|---|---|---|
| Traditional Medicare | No general PA program | Where PA exists (DMEPOS list, some hospital outpatient services): 10 business days, 2 expedited | MAC decides; the supplier or facility usually submits |
| Medicare Advantage | 7 calendar days | 72 hours | CMS-0057-F since January 1, 2026; specific denial reason required; approvals valid for the full course of treatment |
| Medicaid managed care | 7 calendar days | 72 hours | CMS-0057-F since January 1, 2026; several states require faster answers in the MCO contract |
| Commercial (employer) | 2 to 15 business days (state law and contract) | 72 hours for urgent requests | Not covered by CMS-0057-F unless it is a Marketplace plan; self-funded plans follow ERISA timelines |
Clocks start when the plan receives a complete request. Plans may ask once for missing information, which can extend the deadline (up to 14 calendar days for Medicare Advantage). Keep the fax or portal confirmation; it is your proof of the receipt date.
Five things that get authorizations approved faster
Check eligibility and the PA list first
Verify the plan on the day you schedule, then check that plan's current PA list. The payer type tells you the pattern; the plan tells you the rule.
Send the note the reviewer needs
Most pends are missing dates: symptom start, conservative care tried and for how long, and the result. Write those three in the note before you submit.
Match the codes on the request to the claim
Authorize every CPT or HCPCS you expect to bill, with units and the correct site of service. A different code on the claim is a denial.
Track the clock
Log the date and time the plan received the request. When the deadline passes with no answer, call and cite it. Under CMS-0057-F an overdue decision is a compliance problem for the plan.
Go electronic
Payer portals and EHR electronic PA tools return decisions in minutes when the answers match the guideline. Fax is the slow lane.
Diary the expiration
Authorizations have an end date and a unit count. Put both in the practice management system and re-request 30 days before the last covered visit or dose.
Service categories in this lookup
General patterns for each payer type, reviewed by the Revelrex authorization team. Plans change their lists often; when a result and the plan's own list disagree, the plan wins.
Tired of chasing authorizations?
Revelrex handles eligibility, authorizations and the follow-up for practices across the country. Book a 30-minute call and we will walk through your payer mix and where the pends come from. No obligation.