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Prior authorization
Prior-authorization denial appeal checklist
Organize authorization history, payer rules, and supporting records before a response is drafted.
Start with the payer's language
Determine whether the payer says authorization was absent, expired, submitted late, or did not match the service rendered. Those are different issues and need different evidence.
Before anyone drafts a response
- 01Match the authorization number to the member, provider, service, units, and dates.
- 02Collect portal confirmations, call references, faxes, and authorization letters.
- 03Check whether an emergency, continuity-of-care, or retroactive-review rule may apply.
- 04Confirm whether the dispute is authorization, coding, eligibility, or medical necessity.
What a review-ready file usually needs
- Authorization request and payer response
- Call logs, portal receipts, and reference numbers
- Order, clinical rationale, and service records
- Relevant payer rule and a reviewed appeal narrative
- Delivery receipt and escalation owner
Review cautions
- Do not represent a call as authorization unless the record supports it.
- Confirm whether the payer requires a provider appeal, member appeal, or corrected claim.
- Rules vary by payer, plan, service, and jurisdiction.
See the workflow on fictional data.
The denial lab extracts a reason, deadline, review points, and evidence checklist before drafting. No account or real patient data required.