Prior auth was denied but the service was an emergency — am I responsible?
Plans cannot require prior auth for emergency services. ACA §2719A + Prudent Layperson Standard.
Federal law (ACA §2719A) explicitly bans prior authorization requirements for emergency services. The Prudent Layperson Standard governs: the question is whether the symptoms at presentation would have led a reasonable lay person to seek emergency care — NOT whether the eventual diagnosis turned out to be emergent.
Steps
- Call the plan and explicitly cite ACA §2719A + Prudent Layperson Standard
- Document the symptoms at presentation that led you to the ED
- Request that the prior-auth requirement be waived for the emergency visit
- If refused, file internal appeal + complaint with state insurance department
Frequently asked questions
Prior auth was denied but the service was an emergency — am I responsible?
Federal law (ACA §2719A) explicitly bans prior authorization requirements for emergency services. The Prudent Layperson Standard governs: the question is whether the symptoms at presentation would have led a reasonable lay person to seek emergency care — NOT whether the eventual diagnosis turned out to be emergent.
What are the steps?
1. Call the plan and explicitly cite ACA §2719A + Prudent Layperson Standard; 2. Document the symptoms at presentation that led you to the ED; 3. Request that the prior-auth requirement be waived for the emergency visit; 4. If refused, file internal appeal + complaint with state insurance department
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