Prior Authorization Request Template
Three documents and three sheets that build each payer's requirement list from what its reviewers came back and asked for, not its policy.
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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 |
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.
Every free prior authorization request template is the same object: a one-page form with fields for the patient, the payer, the service and code, the diagnosis, a box for clinical rationale and a signature line. Some add a cover letter. That form is not what delays an authorization. Nobody has waited three weeks because they could not find a form. What delays it is the request for more information that arrives before any decision, and no template ranking for this search has anything to say about that.
So the register keeps three sources apart and never merges them. The payer's published criteria, carrying a policy citation and version. This practice's own request-for-information history, item by item, each row carrying the case it came from and a count of how many times that payer has asked. And the payer's own prior authorization statistics, which a Medicare Advantage organization must now publish at contract level by 31 March for the prior calendar year. The middle source is the one nobody keeps, and it is where the unstated requirements live.
Thornbury Orthopaedic Group read one quarter backwards. Of 214 requests across four payer products, 61 came back for more information before any decision. Cascadia Advantage accounted for 30 of those, listing 37 separate items that collapsed to 11 distinct requirements. Five requirements covered 33 of the 37, and 26 of the 30 round trips contained nothing but those five. Four of the five appear in no published document. Each round trip cost a median of nine days, against a standard determination clock of seven calendar days.
What's in the pack
Payer Requirement Register
Eighteen seeded rows across three source types that never merge. Published criteria carry a citation and version, and a payer criteria summary fills that half from the policy document.
The learned rows are the point
Every item a reviewer came back for, in their words, with the exact format required, the case it came from, and a running count of how many times that payer has asked for it.
Authorization Register
Everything in flight with the clock that applies to each request and the date the decision is due, plus which requirement rows the submission covered and which it knowingly omitted. Once approved, it hands over to the authorization tracking pack.
Turnaround Tracking
Our first-pass rate, information request rate and median days on the left. The payer's own published approval, denial and determination figures on the right, with the data year on every row.
Submission Checklist by Payer
The assembly procedure, in the payer's own order, naming who provides each item and what it has to look like. Built to be worked by whoever is covering, not only by the person who learned it.
Medical Necessity Letter
The structure a reviewer reads, answering the payer's criteria one at a time in the payer's order. The clinician supplies and signs every clinical statement, exactly as in the standalone medical necessity letter.
Peer-to-Peer Preparation Note
The one page to have open during the call, and a place to write down what the reviewer actually said afterwards. Pairs with the fuller peer-to-peer preparation run.
Authorization Clock and Follow-up Watch
A weekly read in the order failures reach a patient. Submitted with no confirmation of receipt, past its decision date, approved for fewer units, or expiring inside a course already scheduled. A request whose clock has not started at all because a prescriber's statement is still outstanding is a different failure, and it is tracked in the specialty medication pack.
How to use it
- 1
Open in River, or download it
Open the pack in River and let the agent read your own round trips into the register, or download the blank Word and CSV files instantly and fill them in yourself.
- 2
Send the round trips, not the policies
Every request for more information from the last quarter. Payer letters, portal messages, faxes, a note somebody typed after a phone call. Then denials, approvals with their unit counts and expiry dates, and the policies.
- 3
Watch the items collapse
Thirty letters reduce to eleven requirements and then to the four or five that account for most of them. That collapse is the deliverable, and the count beside each item is what makes it arguable.
- 4
Change the packet, then measure it
Add the repeat items, then watch the first-pass rate per payer move over the next quarter. Denial reasons feed the same register through a denial to authorization loop.
Frequently asked questions
Is this template free?
Yes. Download the whole pack as Word documents and CSV sheets with no credit card. "Edit with AI" is a separate, optional path for practices that want the agent to read their own information requests and build the register from them. Other packs are in the template library.
What format are the downloaded files?
Word documents (.docx) for the three documents and CSV (.csv) for the three sheets, zipped into one file. They open natively in Word, Pages, Google Docs, Excel, Numbers and Sheets, with nothing to convert and no macros to enable.
Does it write the clinical justification?
No, and that boundary is deliberate. The clinician provides and signs every clinical statement, and decides whether a service is medically necessary. The pack organises what the clinician wrote against the payer's stated criteria, in the payer's own order, and tracks what came back. It will not generate a rationale for a patient it has never seen.
Why build the register from information requests instead of the policy?
Because the policy already tells you the criteria your staff know. They are stated, so people learn them. The requirements that send a packet back are the unstated ones: a format, a date range, a specific page flagged. Reading the published policy is still worth doing, and a criteria summary does it well, but it will not surface those.
What if we have no stack of information request letters?
Then start with the last twenty submissions and ask the person who worked them what came back on each. Portal messages count. Phone notes count. A verbal request somebody remembers counts, marked as recalled rather than documented. Twenty cases is enough to find the two or three items that repeat.
What happens when it is denied rather than pended?
A denial and an information request fail differently, so the pack logs them separately. From 2026 a Medicare Advantage denial has to carry a specific reason, which maps onto a register row rather than a category. Where an appeal follows, the denial appeal pack writes it against the criterion the reviewer applied.
Do the payers' published numbers actually exist yet?
For Medicare Advantage contracts, yes. The first posting was due by 31 March 2026 covering the 2025 calendar year, at contract level on the organisation's own website. Commercial plans mostly publish nothing comparable, so those rows stay empty and the tracking sheet reads our own numbers alone.
Find out what your payers keep asking for
Download the blank pack as Word and CSV files, or open this exact pack in River and let the agent read your last quarter of round trips into the requirement register.
Edit with AI