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Prior Authorization Request Template

A submission checklist, medical necessity letter and peer-to-peer note, plus sheets that track what each payer's reviewers ask for, every open request and its deadline.

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Pack of 6 files: 3 documents, 3 spreadsheets

Prior Authorization Request Template

Submission Checklist by PayerDocument
Payer Requirement RegisterSpreadsheet
Medical Necessity LetterDocument
Authorization RegisterSpreadsheet
Peer-to-Peer Preparation NoteDocument
Turnaround TrackingSpreadsheet

Prior Authorization Request Template

Payer Requirement Register

One payer product, one service

Three source types that never merge. The middle block is the one no form ships with.

Requirement	Source type	Asked	In packet
Conservative care attempted for a stated duration	Published policy	n/a	yes
Failure or intolerance of a first-line therapy	Published policy	n/a	no
Conservative care as start and end dates, not a duration	Learned from RFI	11	no
The imaging report, not the images	Learned from RFI	8	no
Referring physician identifier on the form itself	Learned from RFI	6	no
Attestation of no overlapping approved course	Learned from RFI	3	no
Median standard determination, 2025 data year	Payer published	2 days	benchmark

Requirement

Source type

Asked

In packet

Conservative care attempted for a stated duration

Published policy

n/a

yes

Failure or intolerance of a first-line therapy

Published policy

n/a

Conservative care as start and end dates, not a duration

Learned from RFI

The imaging report, not the images

Learned from RFI

Referring physician identifier on the form itself

Learned from RFI

Attestation of no overlapping approved course

Learned from RFI

Median standard determination, 2025 data year

Payer published

2 days

benchmark

Asked counts round trips with this payer in one quarter. Three or more, and still not in the standard packet, is the finding.

A published criterion changes when the payer revises its policy. A learned requirement changes when the payer's practice shifts quietly. Merging the two loses that.

Remaining columns: Plan Or Product, Policy Citation, Policy Version, Policy Date, Learned From Case, Learned On, Format Required, Where It Comes From, Who Provides It, First Pass When Included, First Pass When Omitted, Last Confirmed, Owner.

Page 1 of 1196 words

How to submit a prior authorization request

A prior authorization request asks a patient's health plan to approve a service, such as an MRI or a surgery, before the patient receives it. A complete request names the patient, the plan, the ordering clinician, the service with its codes and units, the diagnosis and the site of care. It shows with dated records how the patient meets each of the plan's coverage criteria, and it is sent in a way that proves the plan received it.

Treat every request for more information as a lesson about that plan. Write down exactly what its reviewer asked for, and in what form, so your next request to the same plan already includes it.

Hands typing on a laptop at a wooden desk, with a stethoscope lying in front of the keyboard — The details on the request must match the plan's own records. Photo: National Cancer Institute on Unsplash

Check whether the plan requires approval

Start from the patient's exact plan, not just the insurer. One insurer may run employer, Medicare Advantage, Medicaid and marketplace plans, each with its own list of services needing approval. Check the current card, then look up the service code and site of care on that plan's list.

When the AMA surveyed 1,000 physicians in December 2025, 62% of those who complete medical service requests said it is difficult to tell whether a service needs prior authorization¹. Search the plan's site for "precertification" and "preauthorization" too, since some plans use those words instead.

Medicare Advantage plans must now post a list of all items and services that require prior authorization² on their websites by March 31 each year. Medicaid managed care plans must post one too³. Wherever you check, note the source, the date and any call reference number, in case the plan later says approval was needed.

What goes in a prior authorization request

Plans differ in their forms and portals, but they all ask for the same core facts, and each fact has a typical slip:

The parts of a complete request

Part	What to include	Typical slip
Patient	Name, date of birth and member ID, exactly as the plan has them	A member ID without its prefix, from last year's card
Ordering clinician	Name, specialty and NPI, with a signed, dated order	An unsigned or undated order
Service	CPT or HCPCS codes, units, frequency and dates	No unit count, so the approval runs out mid-course
Diagnosis	ICD-10-CM codes that match the policy	A code the policy doesn't list for this service
Site of care	Where it will happen, such as an outpatient center	A costlier setting than the policy expects, with no reason given
Evidence	Dated records for each criterion, with pages flagged	A long record with nothing flagged

Next, get the plan's criteria for the service, in the current policy version, and answer each one in the plan's order. Give dates, not durations: "physical therapy from February 2 to March 16, 12 visits" can be checked, while "six weeks of physical therapy" invites a request for the dates.

A letter of medical necessity lays those answers out for the reviewer when the plan wants one. The treating clinician reads and signs every clinical statement.

Submit it and track the deadline

Send the request by a route the plan accepts for that service. Keep proof it arrived, such as a portal confirmation, a fax transmission report, or the name and reference number from a call. Phone is still common: the AMA survey found it was the method physicians used most for medical service requests¹.

Each deadline runs from when the plan receives the request, not when you send it. Ask for an expedited decision when the clinician judges that waiting could seriously endanger the patient's life, health or ability to regain function, and say why.

Federal decision deadlines and extensions

Plan type	Standard	Expedited	If the plan needs more information
Medicare Advantage	7 calendar days	72 hours	Up to 14 more days, only if the patient asks, the plan needs out-of-network records, or circumstances are extraordinary
Medicaid managed care	7 calendar days or fewer, set by the state	72 hours	Up to 14 more days if the patient or provider asks, or the plan needs more information and the delay is in the patient's interest
Employer plans covered by ERISA	15 days	72 hours	One extension of up to 15 days, with a notice saying exactly what is missing and at least 45 days to send it (48 hours if urgent)

Rules for medical services; drug requests can run on different clocks. For other plans, check your contract, the plan documents or state law.

Because a Medicare Advantage plan can extend only in those narrow cases⁴, send everything with the first request. A missed deadline there counts as a denial that can be appealed. With a Medicaid managed care plan, you can ask for up to 14 more days³ if records are slow. An employer plan's extension notice must describe the missing information specifically⁵, so ask for details if it is vague.

Answer requests for more information, then prevent them

A request for more information is not a denial. It means the reviewer found a gap, so answer quickly, in the exact form asked for, by the route the plan names. If something it asked for doesn't exist, say so instead of sending a nearby document.

Then log the item. For each plan, keep a running list of what its reviewers asked for, the format they wanted and how often it has come up. When a plan asks twice for something that was already in the chart, add it to that plan's standard packet.

ExampleOne plan's requests over a quarterAn illustrative example written for this guide

Plan A, lumbar spine MRI: 30 requests for more information in a quarter, listing 37 items.
Conservative care given as a duration, not start and end dates: 11 times.
Images sent without the radiologist's report: 8 times.
Ordering clinician's NPI missing from the plan's own form: 6 times.
Change made: all three now go in every Plan A packet.

Counted, not remembered. Three items explain 25 of the 37, a pattern no one saw case by case.
Form, not content. Each item was already in the chart. The plan wanted it in a different form.

Record the decision and learn from it

When the decision arrives, record the authorization number, the approved codes and units, and the dates it covers. Check them against your request: an approval for fewer units runs out partway through treatment. Set a reminder to renew before the end date.

For a denial, start from the stated reason. Since 2026, Medicare Advantage, Medicaid, CHIP and federal marketplace plans have had to give a specific reason when they deny a prior authorization request⁶, except for drugs. Match it to the criterion it names. Then decide with the clinician whether to send more evidence, ask for a peer-to-peer call or appeal with a prior authorization appeal letter.

Before a peer-to-peer call, give the clinician one page: the plan's criteria in order, the evidence for each and the disputed point. Afterward, note what the reviewer said, since it hints at what that plan wants.

Once a quarter, check that the items you fixed stopped coming back, and compare your numbers with the plan's. Medicare Advantage plans now post yearly figures, such as the share of standard requests approved and the median time to a decision². Read them with care: reviewing 15 Medicare Advantage contracts, the AMA found postings hidden behind provider portals and some with mathematically impossible figures⁷.

Before you submit

You confirmed approval is needed for this code, plan and site of care
Codes, units, dates and site of care match the signed order
Every criterion has dated evidence, with its page flagged
Every item this plan has asked for before is in the packet
You have a route the plan accepts and a way to prove it arrived
The clinician has read and signed the clinical content

Where this guide stops

This guide is general information about US health plan rules, not legal or medical advice. The treating clinician makes the clinical case and signs it. Ask your compliance officer or a health care attorney when a plan's rule or deadline is in dispute.

If a claim is denied after the service, the insurance denial appeal letter template covers that appeal. The template on this page keeps each plan's requirements, open requests and decision times together. River can build the requirement list from your past requests for more information.

How to use this template

Use the files as they are, or open them in River. River asks for your recent requests for more information (payer letters, portal messages, notes from calls), plus denials, approvals and the policies for the services you request most. It turns them into a requirement list for each payer, keeping the payer's published criteria apart from what its reviewers actually asked for.

Then it loads your open requests with the deadline that applies to each, and names the items each payer keeps asking for that your standard packet still lacks. It never writes clinical content or decides medical necessity.

Download it or open it in River
Get the three Word documents and three CSV sheets free, or open the template in River and start from your payers' past requests.
Gather last quarter's requests
Collect every request for more information from the past three months: payer letters, portal messages, faxes and notes from calls.
Build each payer's requirement list
Log each item in the Payer Requirement Register with the format the reviewer wanted, and count repeats, or let River do it.
Fix the packet and track requests
Add repeat items to each payer's checklist, log every open request with its deadline, and record each decision when it arrives.

What's in the template

Payer product	Requests	Came back for more	Rate
Cascadia Advantage	96	30	31%
Fernmoor Select	52	14	27%
Ironwood Commercial	41	11	27%
Aldergate Health	25	6	24%
All four	214	61	29%

Item requested	Times	In the published policy?
Conservative care as start and end dates, not a duration	11	no
The imaging report, not the images	8	no
Referring physician identifier on the form itself	6	no
First-line therapy failure with duration	5	yes
Attestation of no overlapping approved course	3	no
Five items	33	of 37 item-requests

Measure	Thornbury	Cascadia published
Requests in the quarter	96	contract-wide
Came back for more information	31%	not published
Timeframe extended, then approved	not measured	3.8%
Mean days to determination	6.8	3.1
Median days to determination	4	2
Median days, the 30 with a round trip	13	not published
Median days, the 66 without	4	not published

Submission Checklist by PayerWhat to confirm first, what every packet needs, and what each payer asks for beyond its published policy.
Medical Necessity LetterA letter frame that answers the payer's criteria in its order, with dated evidence and the clinician's signature.
Peer-to-Peer Preparation NoteOne page for the call: the stated reason, criteria in order, the disputed point and this payer's past calls.
Payer Requirement Register sheetEach payer's published criteria beside what its reviewers asked for, with the format required and a count.
Authorization Register sheetEvery request with its deadline rule, due date, units approved, authorization number and valid dates.
Turnaround Tracking sheetFirst-pass rate, information request rate and median days per payer, beside the payer's own published figures.

Common questions

What should a prior authorization request include?

A prior authorization request should include the patient's name, date of birth and member ID, and the ordering clinician's NPI. It also needs the CPT or HCPCS codes with units and dates, the diagnosis codes and the site of care. Add dated records that answer each of the plan's criteria, with the relevant pages marked, and the clinician's signature where required.

How long does prior authorization take?

For a medical service, Medicare Advantage and Medicaid managed care plans must decide a standard request within 7 calendar days, and employer plans covered by ERISA within 15. Urgent requests get 72 hours. Extensions can add up to 14 or 15 days. Each clock starts when the plan receives the request, so keep proof of the date.

Why do requests come back asking for more information?

A plan asks for more information when its reviewer can't find something the criteria require, or can't use it in the form sent. Examples include therapy described as a duration instead of dates, imaging sent without the radiologist's report, or an outdated version of the plan's own form. Log each item, and add repeat items to that plan's standard packet.

What is a peer-to-peer review?

A peer-to-peer review is a phone call between the treating clinician and the plan's reviewer, usually a physician, about a request the plan may deny or has denied. It lets the clinician explain the case and point to evidence the reviewer may have missed. Go in knowing which criterion is disputed and where the record supports it, and note the reviewer's reasoning afterward.

Is this prior authorization template free?

Yes. Download the three Word documents and three CSV sheets with no signup. The Payer Requirement Register comes with 18 starter rows, such as "Imaging report rather than the images themselves". The Authorization Register has a sample row for each kind of deadline, so you can see how both work before adding your own. Edit with AI opens the same template in River.

What does Edit with AI do?

It opens the template in a free River workspace and asks for your recent requests for more information, denials, approvals and payer policies. River builds a requirement list for each payer, loads your open requests with their deadlines and names the repeat items your packet still lacks. It never writes clinical content, and nothing goes to a payer unless you send it.

Sources

American Medical Association. “2025 AMA prior authorization physician survey.” ama-assn.org (opens in a new tab)
eCFR. “42 CFR 422.122 — Prior authorization requirements.” ecfr.gov (opens in a new tab)
eCFR. “42 CFR 438.210: Coverage and authorization of services.” ecfr.gov (opens in a new tab)
eCFR. “42 CFR 422.568 — Standard timeframes and notice requirements for organization determinations.” ecfr.gov (opens in a new tab)
eCFR. “29 CFR 2560.503-1: Claims procedure.” ecfr.gov (opens in a new tab)
CMS. “CMS Interoperability and Prior Authorization Final Rule CMS-0057-F.” cms.gov (opens in a new tab)
American Medical Association. “Making payers’ prior authorization data easier to access, understand.” ama-assn.org (opens in a new tab)

Written by

Chandler Supple

Co-founder & CEO, River

Chandler has spent the last six years working in AI, building tools for millions of users and Fortune 100 companies. In 2025, he co-founded River to build a new kind of operating system for AI agents.

LinkedIn GitHub X

Reviewed by

Brian Joseff, Co-founder, River

LinkedIn X

Prior Authorization Request Template

One payer product, one service

How to submit a prior authorization request

Check whether the plan requires approval

What goes in a prior authorization request

Submit it and track the deadline

Answer requests for more information, then prevent them

Record the decision and learn from it

How to use this template

Download it or open it in River

Gather last quarter's requests

Build each payer's requirement list

Fix the packet and track requests

What's in the template

Round trips by payer

What the 30 Cascadia round trips actually asked for

Cascadia Advantage, our numbers and theirs

Common questions

Sources

Chandler Supple

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