“My doctor sent it. Why am I still waiting?” A member asking that question needs more than a status label. They need to know what was received, what remains unresolved, and who can move the request forward.

My approach would be to separate those questions before giving a timeline. This is a research-based service guide, with a fictional example below—not an account of a specific member interaction or an employer procedure.

What changed in 2026

Beginning January 1, 2026, the CMS prior-authorization rule requires affected Medicare Advantage plans to issue decisions on applicable non-drug medical items and services within seven calendar days for standard requests and 72 hours for expedited requests. They must also provide a specific reason when denying a prior-authorization request. Those are decision timeframes, not promises of approval. The rule’s API requirements generally begin in 2027; a representative should not assume every system already exchanges requests automatically. CMS final-rule fact sheet.

The operational detail that matters: an initial authorization request, an appeal, a payment question, and a prescription-drug request are different workflows. One deadline should not be copied into every conversation.

First, identify what is actually pending

After completing the organization’s identity and representative-authorization checks, I would establish:

  1. The request: Which service, provider, location, and intended service date are involved? Is this medical care or a drug request?
  2. The record: Does the plan show receipt, a reference number, and the correct request type? A provider’s “sent” status does not establish what the plan received.
  3. The stage: Is this an initial review, a request for documentation, a denial, or an appeal already underway?
  4. The next owner: Which team or provider office must act, what is needed, and when should the member expect an update?

I would check the applicable deadline and any permitted, documented extension in the approved system. If the member reports that waiting may harm their health, I would promptly use the plan’s urgent-review escalation process and involve the provider. A service representative should not independently decide clinical urgency or tell someone to delay needed care.

Do not confuse the authorization clock with the appeal clock

Medicare calls an Advantage coverage decision an organization determination. When a member disagrees with a denial, the notice explains how to request reconsideration. Medicare currently lists 65 days from the initial denial notice to file a level-one appeal. Standard pre-service appeals generally have a 30-day decision timeframe; qualifying fast appeals have a 72-hour timeframe. Payment and Part B drug appeals have different timelines, and some extensions are allowed. Medicare’s health-plan appeals guidance.

For a denied request, I would read the actual notice with the member, identify the reason, and explain the available appeal route. A documentation follow-up should not silently replace an appeal or cause the filing deadline to be missed.

A fictional call, handled with a concrete next step

Imagine a member’s imaging appointment is approaching. The provider says records were sent, but the plan record shows a documentation request.

A useful response would be:

“I can see the request, but I cannot confirm approval yet. The review record says additional documentation is needed. I’ll help identify exactly what the provider needs to send and confirm the next update point.”

Before making that commitment, I would confirm that the action is within my role. I would record the receiving team, requested information, contact attempt, and agreed follow-up. If the appointment timing raises a concern, I would escalate it through the appropriate process rather than simply repeat the standard deadline.

Make the handoff usable

A good service record separates verified facts, the member’s concern, the unresolved question, and the next action with an owner and follow-up time. At the end of the call, I would ask the member to explain the next step in their own words and clarify anything still uncertain.

That is the contribution I want my work to make: careful investigation, understandable explanations, and follow-through that helps the next person act.

Research reviewed September 15, 2026. General educational guidance; use current plan materials, notices, and employer procedures for an individual case. No member information is included.

Related: How I would explain a complex member question and writing a useful handoff.

Composite, anonymized examples. No real member information. Views are my own and don't represent HCSC (HealthSpring).