Prior Authorization Request (Medical/Support Services)

(Use YYYY-MM-DD date format throughout. For unknown identifiers, state "Unknown—[reason or plan to obtain]" rather than omitting.)

Request Type: [pre-service / concurrent / retrospective]; [standard / expedited-urgent]

Payer: [Payer name and plan product line]

Member Name: [Full name as on insurance card]

Date of Birth: [YYYY-MM-DD]

Member ID: [Member ID number]

Group Number: [Group number, or "Not applicable" if none]

Ordering Clinician: [Name, credentials, NPI]

Practice/Facility: [Name, address, phone, fax]

Contact for Follow-up: [Name, title, phone, best callback times]

Servicing Provider/Vendor: [Name, NPI, provider type] (If applicable for DME supplier, home health agency, or facility)

Requested Service

(Present each distinct service in a compact block. If multiple services are requested, repeat for each. Include codes only if explicitly provided; otherwise state "Codes pending—see clinical description.")

• Service category and level of care: [Service type]
• Specific service or item: [Description]
• Start date: [YYYY-MM-DD]
• Duration/quantity: [Days, visits, units, or hours/week]
• Frequency/intensity: [Frequency and intensity requirements]
• ICD-10 codes: [Codes if provided]
• CPT/HCPCS codes: [Codes if provided]
• Clinical priority: [One-line urgency statement if applicable]

Summary

[3–6 sentence paragraph: primary diagnosis and key comorbidities; current clinical/functional status; what is requested and why needed now; anticipated benefit if approved; specific risk or harm if delayed or denied]

Clinical Narrative

(Include only facts relevant to the authorization decision. If clinical evaluation was limited, state the limitation.)

Diagnosis and Severity

• [Primary diagnosis with onset or acute event date]
• [Severity markers relevant to service need]
• [Pertinent comorbidities impacting requested service]

Current Clinical Status

• [Current symptoms, stability, and safety concerns]
• [Relevant exam findings, vitals, or medications]
• [Assessment limitations if applicable]

Functional Status

• [Mobility: transfers, gait, assist level, device use, fall history]
• [ADL/IADL limitations: bathing, toileting, dressing, feeding, medication management]
• [Cognitive or behavioral factors affecting safety]
• [Home environment, accessibility, and caregiver availability]

Supporting Objective Data

• [Relevant test/study with date, result, and relevance to request]
• [Therapy evaluations with dates and key measures]
• [Wound measurements if applicable: location, stage, dimensions, characteristics]

Treatment History and Response

• [Prior treatments attempted with dates and outcomes]
• [Prior episodes of requested service and measured outcomes]
• [Contraindications or reasons alternatives are inappropriate]

Medical Necessity Rationale

(Map clinical facts to coverage criteria. Reference payer policy by name/version if known. If evidence is pending, state what is pending and expected availability.)

• Criterion: [Coverage requirement or medical necessity element]

  Evidence: [Patient-specific facts with dates]

  Conclusion: [Why criterion is met]

• Criterion: [Level/intensity appropriateness]

  Evidence: [Severity, functional data, safety needs]

  Conclusion: [Why requested level is necessary]

• Criterion: [Duration appropriateness]

  Evidence: [Time-bound goals and reassessment plan]

  Conclusion: [Why duration is justified]

(Add additional criteria as needed based on payer requirements.)

Alternatives Considered

• [Conservative management attempted with dates and outcomes; why insufficient]
• [Lower level of care considered; why unsafe or inadequate]
• [Alternative equipment or formulary options; why not clinically appropriate]

Urgency Justification

(Include only if expedited review is requested or discharge/procedure timing drives the request; omit for routine requests.)

• Urgency category: [Expedited / urgent]
• Time anchor: [Discharge date, procedure date, or clinical deadline]
• Risk from delay: [Specific harm if delayed beyond date] due to [patient-specific facts]

Service-Specific Documentation

(Include only the module relevant to the requested service. Omit non-applicable modules.)

Home Health Services

• Homebound status: [Patient-specific reasons leaving home is difficult or contraindicated; required assistance and devices]
• Skilled need: [Discipline(s)] for [specific condition] with [measurable goals]
• Visit plan: [Discipline, frequency, and duration]
• Face-to-face encounter: [Date and provider type] (Must be within 90 days before or 30 days after start of care)

DMEPOS / Orthotics / Prosthetics

• Item requested: [Item description; HCPCS if known; quantity; rental vs purchase]
• Functional limitation addressed: [Deficit the item mitigates and intended use]
• Lesser equipment considered: [Why alternatives are inadequate]
• Supporting encounter: [Date and objective findings; face-to-face within 6 months if required]
• Order status: [Compliant written order attached / pending]

Post-Acute Facility (SNF/IRF/LTACH)

• Index hospitalization: [Admit date, expected discharge date, brief course]
• Ongoing skilled needs: [Wound care, IV meds, monitoring, complex medication management]
• Therapy needs: [Required intensity in minutes/day; why lower intensity is insufficient]
• Functional status and supervision: [Assist levels, fall risk, cognitive factors]
• Proposed length of stay: [Days/weeks]; Discharge goals: [Measurable goals]; Discharge destination: [Planned setting]

Personal Care / Support Services

• ADL/IADL limitations: [Specific tasks impacted with safety implications]
• Caregiver availability: [Available supports and why insufficient]
• Requested tasks and hours: [Task list with frequency and time to justify total hours/week]

Attachments

(List all documents submitted. If expected attachment is missing, state why and when it will be provided.)

• [Recent progress note, date]
• [Discharge summary, date] (If post-acute request)
• [Therapy evaluations, dates]
• [Relevant imaging or lab reports, dates]
• [Current medication list, date]
• [Orders with dates] (DME order, home health plan, etc.)

Requested Determination

• Approval requested: [Service type, site of care, units/visits/days, start and end dates]
• Special handling: [Continuity of care / transition authorization / single-case agreement] (If applicable)
• Peer-to-peer availability: [Clinician name, credentials, phone, best times]

Attestation and Signature

I attest that the information provided is accurate and reflects patient-specific details from the medical record. Additional records can be furnished promptly upon request.

Clinician Signature: ____________________ Date: [YYYY-MM-DD]

Printed Name, Credentials, NPI: [Name, credentials, NPI]