New York prior authorization laws (2026)
General reference compiled from public statutes and the AMA state-law chart. This is not legal advice. Statutes change; confirm the current law before relying on it.
Decision deadlines
Prior authorization (Commercial issuers and their utilization review agents (NY-regulated plans))
Standard decision: 3 business_days.
NY Insurance Law § 4903(b)(1) · sourcePatient-protection mandates
Same Specialty Reviewer
An adverse determination may only be rendered by a clinical peer reviewer, defined as a physician or a same-profession health care professional in the same or similar specialty as the provider who typically manages the condition or furnishes the service under review.
NY Insurance Law § 4900 (clinical peer reviewer) and § 4903(a)(2) · sourceRetrospective Denial Prohibition
Once a service has been pre-authorized, the insurer/MCO may not retrospectively deny the claim except in narrow circumstances (member not covered at service, untimely claim, benefit limitation exhausted between approval and service, approval based on materially inaccurate information, or reasonable suspicion of fraud).
NY Insurance Law §§ 3217-b and 4325; Public Health Law § 4905 · sourceFrequently asked questions
How long does an insurer have to decide a prior authorization in New York?
Under NY Insurance Law § 4903(b)(1), a standard prior authorization decision is generally due within 3 business_days. Confirm the current statute, as timeframes vary by plan type.
What prior authorization patient protections does New York have?
New York law includes same specialty reviewer, retrospective denial prohibition. Each is grounded in a specific statute (see above).
Other states
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