Medicare Advantage prior authorization call script for late decisions
Since January 1, 2026, a plan must decide a standard request within seven calendar days. A missed deadline counts as a denial the patient can appeal.
Co-founder, JotPsych
You sent a Medicare Advantage plan a prior authorization request for transcranial magnetic stimulation (TMS) eight days ago. You're still waiting, and the plan's deadline has passed. Call the plan today.
The rule behind the call
Under a 2024 federal rule, Medicare Advantage and Medicaid plans have seven calendar days to decide, starting the day after the plan receives your request. Weekends count.
The deadline is in the Code of Federal Regulations (CFR) at 42 CFR 422.568. The section treats a missed deadline as a denial: "this failure itself constitutes an adverse organization determination and may be appealed."
I'm calling about a standard prior authorization request for [patient name], member ID [number].
Your plan received the request on [date], more than 7 calendar days ago.
Under 42 CFR 422.568(b), the plan had to decide within 7 calendar days.
The regulation says a missed deadline "itself constitutes an adverse organization determination and may be appealed."
Please give me the decision today, and a reference number for this call.
The deadline and the quoted words come from 42 CFR 422.568, in effect for prior authorization since January 1, 2026. Keep the reference number with your copy of the request.
When to use the script
Use the script on day eight, by phone. You'll need the date the plan received your request, from the fax confirmation or the portal's receipt.
| S | M | T | W | T | F | S |
|---|---|---|---|---|---|---|
| 1 | 2 | 3 | ||||
| 4 | 5 | 6 | 7 | 8 | 9 | 10 |
| 11 | 12 | 13 | 14 | 15 | 16 | 17 |
| 18 | 19 | 20 | 21 | 22 | 23 | 24 |
| 25 | 26 | 27 | 28 | 29 | 30 | 31 |
- Plan receives the request
- Day 7: decision due
- Day 8: call the plan
- Seven calendar days to decide
Under 42 CFR 422.568(b), a request the plan receives on Monday, October 5, is due a decision by Monday, October 12. The day-eight call goes out Tuesday, October 13.
You may hear that the plan took an extension. Ask why. The regulation allows up to 14 more days only in narrow cases, such as when the patient asks for more time. Then the plan must explain the delay to your patient in writing. Ask for that notice for your records.
Madison Hynes, an associate director of government affairs at the Medical Group Management Association, expects "faster turnarounds for both standard and expedited requests." "We are anxious to see if that is really being implemented on the ground," Hynes added.
What plans post
Each Medicare Advantage plan posts its prior authorization numbers by March 31 for the year before, under a federal regulation. Find the report for each plan you send requests to, and compare the plan's approval rate with your own. Humana's report for contract H5216 is one example.
Humana's posted 2025 report for contract H5216, published under 42 CFR 422.122. The shares count every standard request on the contract, from every practice.
UnitedHealthcare limits each approval to the dates listed on it. Its 2026 administrative guide says: "Advance notification or prior authorization is valid only for the date of service or date range listed on it." Check the dates on each approval before you book a session under it.
If the plan approves on the call, record the approval's number, dates, and CPT scope in JotPsych. The record goes on the patient's Insurance page and counts the visits documented within those dates.
See JotPsych- Madison Hynes, MPP, and James Haynes, JD, associate directors of government affairs at the Medical Group Management Association (MGMA), “MGMA Government Affairs: 2026 Washington Update”, MGMA 2026 Annual Conference, San Antonio, September 27, 2026.
- Centers for Medicare & Medicaid Services (CMS), Interoperability and Prior Authorization Final Rule (CMS-0057-F) fact sheet, January 17, 2024; the rule is 89 Federal Register 8758, February 8, 2024.
- 42 CFR 422.568, Standard timeframes and notice requirements for organization determinations, paragraphs (b) and (f), eCFR, read October 1, 2026.
- 42 CFR 422.122, Medicare Advantage prior authorization requirements, paragraph (c), via the Legal Information Institute, Cornell Law School.
- Humana, Medicare Advantage prior authorization metrics, contract H5216, plan year 2025, posted March 2026.
- UnitedHealthcare, 2026 Care Provider Administrative Guide for Commercial, Individual Exchange, and Medicare Advantage, chapter 7, page 89.