Prior Authorization Request Letter

TODAY'S DATE

PAYER NAME
Prior Authorization Department
PAYER FAX / ADDRESS

RE: Prior Authorization Request
Patient: PATIENT FULL NAME
Date of Birth: MM/DD/YYYY
Member ID: MEMBER ID
Group Number: GROUP NUMBER
Requesting Provider: PROVIDER NAME, CREDENTIALS
NPI: NPI NUMBER
Tax ID: TAX ID
Requested Procedure: PROCEDURE NAME
CPT / HCPCS Code(s): CODES
Requested Service Date: DATE OR DATE RANGE
Facility: FACILITY NAME AND ADDRESS

Dear Prior Authorization Review Team,

We are requesting prior authorization for PROCEDURE/SERVICE NAME for the above-referenced patient. This request is supported by the following clinical information.

Diagnosis and Clinical Background:

The patient presents with a primary diagnosis of PRIMARY DIAGNOSIS — ICD-10 CODE AND DESCRIPTION. 2–3 sentence clinical history: onset, prior treatments, current status, why this intervention is appropriate now.

Medical Necessity Justification:

The requested service is medically necessary because CLINICAL REASON — e.g., "the patient has failed conservative management with [treatments] over [time period] and presents with [specific clinical indicators]". This is consistent with PAYER NAME's coverage criteria for SERVICE TYPE, specifically POLICY NUMBER / TITLE, PAGE / SECTION REFERENCE.

Prior Treatments Attempted:

• TREATMENT 1 — dates, outcomes
• TREATMENT 2 — dates, outcomes
• TREATMENT 3 — if applicable

Supporting Clinical Documentation Attached:

• Office visit notes (most recent N visits)
• Relevant diagnostic results: LABS / IMAGING / STUDIES
• Letter of medical necessity from treating physician
• ADDITIONAL DOCUMENTATION

We respectfully request expedited review given CLINICAL URGENCY / SCHEDULED DATE. Please notify our office of your determination at CONTACT PHONE or via fax at FAX NUMBER.

Respectfully,

PROVIDER NAME, CREDENTIALS
PRACTICE / FACILITY NAME
PHONE | FAX