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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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What you get

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
RiverPrior 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.

RequirementSource typeAskedIn packet
Conservative care attempted for a stated durationPublished policyn/ayes
Failure or intolerance of a first-line therapyPublished policyn/ano
Conservative care as start and end dates, not a durationLearned from RFI11no
The imaging report, not the imagesLearned from RFI8no
Referring physician identifier on the form itselfLearned from RFI6no
Attestation of no overlapping approved courseLearned from RFI3no
Median standard determination, 2025 data yearPayer published2 daysbenchmark

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.

One quarter, read backwards

Round trips by payer, the items they collapse to, and the practice's numbers beside the payer's own published numbers.

Prior Authorization Request Template
RiverRound trips

Round trips by payer

Illustrative figures for a fictional practice, Thornbury Orthopaedic Group, over one quarter.

Payer productRequestsCame back for moreRate
Cascadia Advantage963031%
Brightpath Select521427%
Ironwood Commercial411127%
Aldergate Health25624%
All four2146129%

Not one of these 61 was a denial. Every one of them was a request for something before any decision was made, which is why none of them appears in a denial report and none of them has a reason code. A practice reading only its denials cannot see this column at all.

The register separates information that was already available at submission and was omitted from information the reviewer genuinely needed. Only the first kind is avoidable, and only the first kind belongs in the arithmetic.

RiverThe five items

What the 30 Cascadia round trips actually asked for

Item requestedTimesIn the published policy?
Conservative care as start and end dates, not a duration11no
The imaging report, not the images8no
Referring physician identifier on the form itself6no
First-line therapy failure with duration5yes
Attestation of no overlapping approved course3no
Five items33of 37 item-requests

Thirty letters, 37 item-requests, 11 distinct requirements, five that matter. The remaining six requirements account for four requests between them across the whole quarter, which is the definition of noise.

26 of the 30 round trips listed nothing but those five items. Add all five to the standard Cascadia packet and 26 of the 30 do not happen. The other four each carried something from the tail as well.

One of the five is in the payer's medical policy, so it is a straightforward packet fix. Four are in no published document anywhere and can only be learned from the practice's own round trips.

RiverUs against them

Cascadia Advantage, our numbers and theirs

MeasureThornburyCascadia published
Requests in the quarter96contract-wide
Came back for more information31%not published
Timeframe extended, then approvednot measured3.8%
Mean days to determination6.83.1
Median days to determination42
Median days, the 30 with a round trip13not published
Median days, the 66 without4not published

One round trip costs nine days. Thirteen against four. The standard determination clock for these services is seven calendar days, so a single round trip costs the practice more elapsed time than the entire clock it is waiting on.

26 round trips at nine days each is 234 patient-days. That is the number worth putting in front of whoever decides how the standard packet gets assembled.

The 31% and the 3.8% measure adjacent things, not the same thing, and the published figure covers every service the contract touches rather than one specialty. A small gap between them would be noise. Eight times is not, and the caveat travels with the comparison every time it is made.

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What's in the pack

01

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.

02

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.

03

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.

04

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.

05

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.

06

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.

07

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.

08

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. 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. 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. 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. 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.

Sources

  1. eCFR42 CFR 422.122 — Prior authorization requirements (opens in a new tab)
  2. eCFR42 CFR 422.568 — Standard timeframes and notice requirements for organization determinations (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.

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Reviewed by

Brian Joseff, Co-founder, River

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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