Written by a parent, not a doctor. Nothing here is medical advice.

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Pennsylvania program

Deadlines for a treatment approval (prior authorization)

Pennsylvania sets deadlines for covered health plans to answer requests for treatment approval. Urgent care and medicines have shorter clocks.

What it is

Pennsylvania sets deadlines for covered health plans to answer requests for treatment approval. Urgent care and medicines have shorter clocks.

A treatment request does not have to sit unanswered indefinitely. Pennsylvania sets different deadlines for standard care, urgent care and medicines. The kind of plan and a complete request decide which clock applies.

Eligibility rules
  • Act 146 of 2022 sets prior-authorization rules for insured plans from January 1, 2024.
  • These Pennsylvania clocks do not automatically apply to a private employer’s self-funded plan. Public-employee, school and church coverage needs an additional check of the policy, funding and any special or voluntarily adopted rules. Your social worker can help the clinic identify the governing deadline; a company logo on the insurance card is not enough.
  • If the plan wants your child to try a cheaper medicine first, the oncologist can ask for an exception by explaining why that medicine would be unsafe, would not work, or has already been tried. The plan has to consider those reasons.
What you get
  • A standard treatment decision within 15 days, or 72 hours when urgent.
  • Drug decisions within 24 hours when urgent, or two business days otherwise, never exceeding 72 hours.
  • Up to 60 days of continued care after certain plan-initiated network changes.
What the help includes
  • Covered commercial non-drug requests generally have a 15-day ordinary deadline or a 72-hour urgent deadline. A qualifying urgent request to extend ongoing care can have a 24-hour deadline when submitted at least 24 hours before the current approval ends. Missing-information rules and faster Medicaid managed-care requirements need a separate check.
  • Covered drug prior authorizations and step-therapy exceptions generally have a 24-hour urgent deadline or a two-business-day nonurgent deadline that cannot exceed 72 hours. The clinic and plan should identify the request’s receipt date and any legally permitted information request rather than assuming every clock starts over.
  • If the plan drops your child's doctor from its network through no fault of the doctor, your child can keep seeing them for up to 60 days, longer if the treatment needs it.
If you decide to apply
  1. The clinic can record the request’s receipt date and check the deadline and missing-information rules.
  2. Ask the oncologist to explain the urgency if waiting could harm your child.
  3. If the answer is late, ask the Insurance Department about a complaint using the request and reference number.

Pennsylvania Insurance Department: 877-881-6388 · Official page ↗

After you ask
  • An approval states what the plan has agreed to cover. A denial gives the basis for an appeal.
  • A missed answer deadline can support a complaint to the Insurance Department at 877-881-6388. It is different from appealing the medical merits of a denial.
Good to know

An information request does not automatically restart a full decision clock. The clinic and plan can identify how the rules affect your request.

Other details
  • A complete request and a record of later information requests help establish the timing.
  • Act 146’s principal requirements took effect January 1, 2024. Public-employee, school and church coverage needs a plan-specific review of funding and applicable rules.
Official sources
Ask your social worker

“If treatment needs plan approval, which decision deadline applies and how do we know the request is complete? Could you help us seek urgent handling or challenge a late answer if appropriate?”

Why I’m asking: I want to know when we should have an answer so treatment is not delayed by an unclear request.

More background and detailed requirements
Additional program information and published rules

Who does what

The three parts, side by side. The agency decides; nobody on this page does.

You

Ask the clinic what date the deadline ran out and call the plan on that date.

Your social worker

The social worker tracks the request dates.

The care team

Marks urgent requests urgent and names the deadline.

Who decides
The plan; the state Insurance Department enforces.
Ask the care team
“Can you file this as urgent and note the state deadline (72 hours for services, 24 hours for drugs) on the request?”

How to apply

First step: Ask the clinic to mark urgent requests urgent and to note the deadline on the request.

  1. Ask the clinic to mark urgent requests as urgent and to note the 72-hour and 24-hour clocks.
  2. If a provider is dropped, ask the plan in writing for 60 days of continuity.

Where it starts: Name the Act 146 clock in the prior-authorization request; complain to the Insurance Department at 877-881-6388 if it is missed.

What to gather

  • The request date and reference number
  • The plan's answer date

How long: Commercial non-drug requests generally use 15 days standard or 72 hours urgent. Covered drugs use 24 hours urgent or two business days, not exceeding 72 hours, otherwise. Ongoing-care and Medicaid rules can be faster.

What a yes looks like

An approval by the deadline.

What a no looks like, and the next move

The denial notice identifies the internal review route and deadline. A final adverse determination can start the external-review window. A missed response deadline and the medical merits are separate issues.

Watch out

  • An information request affects timing only under the applicable request-type rules. The clinic records receipt, missing-information notices and response dates; a new full clock does not automatically restart.
  • Self-funded, state-employee and teacher plans: we could not confirm the rules reach them; ask the plan for its deadlines.
  • PEBTF has its own internal appeal process. State external review excludes self-funded plans, but that alone does not settle all public-plan authorization duties. PEBTF and teacher-plan adoption of the state clocks remains unverified.

If they say no, quote this: Prior-authorization deadlines: Act 146 of 2022, §2155. Continuity of care: 31 Pa. Code §154.15.

The numbers and the rules

The arcane layer, kept on purpose. Checked September 10, 2026.

What it is worth

Prior authorization within 15 days (standard) or 72 hours (urgent); drug requests within 24 hours (urgent) or two business days; up to 60 days of continued care after a provider is dropped.

  • $15 — Standard non-drug prior authorization
  • $72 — Urgent non-drug service not yet started
  • $24 — Urgent drug prior authorization or step-therapy exception
  • $2 — Non-urgent drug request
  • $60 — Continuity of care after a plan-initiated provider termination

Legal protection: Outer decision clocks on prior authorization for insured plans · Up to 60 days of continued care from notice when a managed-care plan terminates a provider without cause, with clinical extensions possible

What it costs the family: None.

The eligibility facts, as published

Plans
insured plans under the Insurance Company Law (Act 146 of 2022, from 2024-01-01); managed-care continuity under 31 Pa. Code §154.15
Not verified
self-funded, state-employee and teacher plan applicability; gold-card exemption; complete step-therapy exception grounds

The trap: Assuming these rules reach a self-funded, state-employee or teacher plan. We could not confirm that; ask the plan for its own deadlines.

Where I read this

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