Prior Authorization Request (Outpatient SLP Therapy)

Date Prepared: [Date prepared]    Date Submitted: [Date submitted]    Request Type: [Initial / Continuation / Re-evaluation Update]

Payer: [Payer name]    Plan Type: [Plan type]    Reference Number: [Reference number or "Pending payer assignment"]

Patient Name: [Patient full name]    DOB: [DOB]    Member ID: [Member ID]    Group ID: [Group ID]

Rendering SLP: [Name, credentials, NPI, state license, clinic address, phone/fax]    Referring/Ordering Clinician: [Name, credentials, NPI, contact]

Services Requested

Discipline: Speech-Language Pathology
Number of Visits Requested: [Number of visits]
Date Span: [Start date] – [End date]
Proposed Frequency: [Number] visits/week
Session Length: [Minutes] minutes
Procedure Codes: [CPT/HCPCS codes and modifiers] (Only include if explicitly known; do not infer codes.)

Primary ICD-10 Diagnosis: [Primary diagnosis description and code] (If diagnosis code is pending, write: "Diagnosis code pending; see attached evaluation impression." Do not invent or infer ICD-10 codes.)
Secondary/Comorbid Conditions: [Diagnoses materially affecting prognosis, safety, or intensity] (Only include if materially relevant to treatment planning.)

Clinical Summary

[Referral reason and key symptoms. Onset or exacerbation date with clinical course. Prior level of function as baseline.] (Write 1–2 paragraphs establishing why therapy is needed now and what is functionally at stake.)

[Current functional impact on activities and participation: ability to follow directions, express needs, safe oral intake, medication management, work/school tasks, social participation, independent living. Safety risks if present. Relevant prior SLP services.] (Include only comorbidities, barriers, or supports that materially affect the care plan. Omit if none are relevant rather than stating "none.")

Baseline Objective Findings

Evaluation Date: [Date]
Assessment Methods: [Standardized tests with full names, criterion-referenced probes, instrumental assessments, clinical observations]

• [Standardized scores with severity interpretation] (Report exact scores; do not approximate or invent.)
• [Task-level findings with objective metrics: accuracy %, cueing level, intelligibility %, response latency]
• [Diet level and swallow safety status] (Include for dysphagia cases; reference instrumental study results if completed.)
• [Comparison to prior baseline with objective data] (Include only for continuation requests.)

Prognosis: [Good / Fair / Guarded] — [Brief rationale grounded in findings and supports/barriers. Expected timeframe for measurable change.]

Prior Response to Therapy

(Include this section only for continuation or extension requests. For initial requests with no prior therapy, write: "No prior SLP therapy for this condition in past [timeframe] per patient report" and omit the remainder.)

• Prior Episode: [Start date] – [End date]; [Visits authorized] authorized / [Visits completed] completed; Attendance: [Attendance pattern]
• Goal Attainment: [Goal status with objective metrics compared to baseline]
• Plateau/Regression Factors: [Contributing factors and how the plan addresses them] (Omit if not applicable.)
• Rationale for Additional Visits: [Why additional visits are needed and what will differ in the upcoming period]

Plan of Care

• Treatment Focus Areas: [Specific skilled targets aligned to diagnosis and functional needs]
• Intervention Approaches: [Planned intervention categories, purpose, and generalization plan]
• Safety Considerations: [Relevant precautions or contraindications] (Omit if none.)
• Home Program/Caregiver Training: [Training focus, frequency, and competency validation approach]
• Therapy Dose: [Individual / Group / Caregiver training], [Number] visits/week × [Number] weeks; Total visits: [Number]; Reassessment: [Cadence]
• Discharge Criteria: [Functional triggers: goal achievement, independent home program, maximal benefit] (For chronic/progressive conditions, include criteria for transition to maintenance vs ongoing skilled care.)

Functional Goals

(Goals must be functional, measurable, and time-bound. Specify target behavior, conditions/supports, measurement method, and timeframe. Avoid non-measurable verbs like "understand" or "improve" without a metric.)

Long-Term Goals:

• [LTG 1: Target behavior, conditions, metric, timeframe]
• [LTG 2: Target behavior, conditions, metric, timeframe] (Include only if needed.)
• [LTG 3: Target behavior, conditions, metric, timeframe] (Include only if needed.)

Short-Term Goals:

• [STG 1: Component skill, metric, timeframe]
• [STG 2: Component skill, metric, timeframe]
• [STG 3: Component skill, metric, timeframe]
• [STG 4: Component skill, metric, timeframe] (Include only if needed.)
• [STG 5: Component skill, metric, timeframe] (Include only if needed.)

Medical Necessity Rationale

[Narrative addressing: (1) the disorder produces material functional limitations and/or safety risk; (2) services require SLP clinical judgment that cannot be performed by unskilled personnel; (3) reasonable expectation of measurable improvement within a reasonable timeframe, or skilled maintenance is required to prevent deterioration; (4) requested dose is appropriate for severity and goals.]

Skilled Care Statements:

• [Statement demonstrating need for SLP expertise, e.g., analysis and modification of strategies based on physiologic response; graded cueing hierarchies with data-driven task selection; caregiver training with competency validation]
• [Additional skilled-care statement] (Include only if applicable.)

Risk of No Treatment: [Potential functional decline, safety risk, or preventable complications if therapy is not provided]

Physician Involvement

Referral/Order: [Ordering clinician name and credentials] on [Date]; [Order status]
Plan of Care Certification: [Signed / Pending / Sent on date] (If pending, note date sent and planned follow-up.)

Attachments

• Initial evaluation report: [Attached / Available upon request]
• Re-evaluation or progress report: [Attached / Available upon request / N/A]
• Objective test score summary: [Attached / Available upon request]
• Instrumental study reports (MBSS/FEES): [Attached / Available upon request / N/A]
• Physician referral or order: [Attached / Available upon request]
• Signed plan of care: [Attached / Available upon request / Pending]

Authentication

Clinician Signature: ______________________    Credentials: [Credentials]    Date: [Date]

Ordering Clinician Signature: ______________________    Date: [Date]
(Include only if required by payer.)

This submission contains information necessary to support medical necessity for the requested services and is transmitted via secure processes consistent with minimum necessary standards.