How long do Certificate of Need approvals add to healthcare development timelines?

In most CON states, approvals add roughly 4–8 months for straightforward projects and 9–18 months for contested or complex projects, with rare cases extending beyond two years due to appeals.

Why it matters

Time is capital. Every month added to schedule increases construction escalation (often 5–8% annually in healthcare) and interest carry. For a 40,000–60,000 SF ambulatory surgery center (ASC) budgeted at $400–$700 per SF, a six-month delay can translate to $1.0–$2.5 million in combined escalation and financing costs, plus deferred service-line revenue. The impact compounds when CON timing pushes procurement of long-lead clinical equipment.

Market dynamics heighten the stakes. In competitive regions like Nashville and Middle Tennessee, opponent filings can extend the process by 6–12 months. Because CON determinations affect market entry, bed capacity, imaging, and surgical access, the approval path is a strategic lever that should be integrated early into capital and portfolio planning, as outlined in our healthcare real estate services.

How it works

The Certificate of Need process is state-specific, but common steps include: noticing intent to file, application completeness review, staff analysis, public comment, a hearing, decision, and an appeal window. Across states tracked by the National Conference of State Legislatures (NCSL) and the American Health Planning Association (AHPA), typical administrative reviews run 90–180 days from a complete application to decision. Appeals can add 6–12 months, particularly where opponents request administrative hearings and subsequent judicial review.

In Tennessee, the Health Facilities Commission meets monthly and publishes filing deadlines and agendas; from notice of intent through a final vote is often 90–150 days for uncontested filings, based on published calendars. Similar windows exist in Georgia (approximately 90–120 days) and North Carolina (often 120–180 days), according to AHPA compendia and state agency schedules. Projects that trigger high scrutiny—such as new inpatient beds, freestanding emergency departments, ASCs in constrained markets, or new MRI installations—are more likely to draw opposition and extend timelines.

Key considerations

Define the trigger and scope early. Many states require CON for specific services (e.g., ASCs, MRI/CT, NICU, cardiac catheterization) or capital thresholds (often $2–$10 million), while some renovations or physician-office ancillary services may be exempt. Align the project definition, service lines, and site with the state’s need methodology before design development. An Authority Having Jurisdiction (AHJ) may include the state health planning agency and, separately, building and life-safety authorities; sequencing approvals across agencies reduces rework.

Plan the schedule as a concurrent track. Run programming, schematic design, and financial feasibility in parallel with CON so the record is supported by clinical and operational data without waiting on late-stage design. Locking a preliminary program allows a construction manager at risk (CMAR) to offer an early Guaranteed Maximum Price (GMP) concept, anchoring the pro forma while preserving flexibility. Anticipate key lead times: imaging and surgical equipment at 20–40 weeks; air-handling units at 24–30 weeks; and utility upgrades requiring 12–20 weeks of coordination. A realistic predevelopment cadence is 8–12 weeks for program and concept design, 12–16 weeks for design development and early permitting, and 10–14 weeks for land use and due diligence—calibrated to a 4–8 month CON window.

Actionable takeaway

Treat CON as a gated but concurrent workstream, not a pause button. Use a 12–18 month “predevelopment and entitlement” phase that blends need analysis, preliminary design, site control, and community engagement, and target a filing that is evidence-rich and opposition-ready. For governance clarity and calendar certainty, outline decision points and risk scenarios in advance, as seen in our advisory approach, and if your state requires CON, engage local counsel and a planning consultant before schematic design is 30% complete. To discuss project phasing or schedule-risk mapping, connect with our team via confidential consultation.

What are the biggest timeline drivers inside a CON process?

The longest intervals are typically the public notice period, completeness review, and the queue to a hearing date. Contested cases add months for discovery and hearings, and an appeal can extend the process by 6–12 months beyond the initial decision.

Which projects most often require CON review?

Common triggers include new or expanded inpatient beds, ASCs, freestanding emergency departments, cardiac catheterization labs, and advanced imaging like MRI or PET. Some states also trigger review based on capital cost thresholds or service relocations.

How does Tennessee compare to other states?

Tennessee typically runs 90–150 days from notice to decision for uncontested applications, aligned with monthly Health Facilities Commission meetings. Timelines lengthen when opposition arises or when projects involve multiple services or counties.

Can we advance design and procurement during CON review?

Yes, with guardrails. Many systems progress programming and schematic design and solicit preliminary CMAR input for a conceptual GMP, but avoid irreversible commitments until after approval. Long-lead submittals can be prepped to release immediately post-approval.

What helps in contested CON cases?

Data-rich need methodologies, patient origin analyses, physician commitment letters, payer mix modeling, and access metrics strengthen the record. Early community engagement and phased service introductions can also mitigate opposition while meeting documented need.

Bremner Healthcare Real Estate partners with health systems to align real estate strategy with clinical performance and capital efficiency.