What is a prior authorization letter?

A prior authorization letter is a formal request to an insurance company seeking approval for a specific medication, procedure, or service before it is provided. It includes patient information, clinical justification, and supporting documentation to demonstrate medical necessity.

When is prior authorization required?

Prior authorization is typically required for expensive medications, non-formulary drugs, specialty procedures, advanced imaging (MRI, CT), surgical procedures, durable medical equipment, and services outside standard treatment protocols.

How long does prior authorization take?

Standard prior authorization decisions typically take 5-15 business days. Urgent requests may be processed within 24-72 hours. Denials can be appealed, which adds additional time to the process.

What information is needed for a prior authorization?

Required information includes patient demographics and insurance ID, ICD-10 diagnosis codes, CPT procedure codes (if applicable), clinical justification for medical necessity, documentation of prior treatments tried, and supporting clinical notes or test results.

What should I do if a prior authorization is denied?

If denied, first review the denial reason carefully. You can request peer-to-peer review with the insurance medical director, submit additional documentation, or file a formal appeal within the allowed timeframe (typically 180 days). Document step therapy failures, cite clinical guidelines, and include new clinical information not in the original request.

Prior Authorization Letter Template - Free Medical PA Template

Administrative — Prior Authorization Template

Administrative Utilization Management Updated: 11/7/2025

The Prior Authorization Letter Template is an essential resource for physicians, nurse practitioners, and administrative staff navigating the insurance prior authorization process for medications, procedures, and services. This comprehensive template provides the structured format and medical necessity language required by insurance companies to approve coverage for treatments that require pre-authorization. The template includes patient demographic and insurance information, healthcare provider credentials, specific service or medication requesting authorization, relevant ICD-10 diagnosis codes with clinical justification, detailed clinical rationale for medical necessity, documentation of previous treatments tried (step therapy requirements), supporting clinical evidence and guidelines, expected outcomes and risks of not providing treatment, and professional attestation language. This template streamlines the often time-consuming PA process, ensures inclusion of all required elements to minimize denials and delays, supports compliance with insurer requirements, and protects provider time by standardizing documentation. The structured format is adaptable for medication prior authorizations (expensive or non-formulary drugs), procedure authorizations (surgical procedures, imaging, diagnostic tests), durable medical equipment (DME), specialty referrals, and other services requiring pre-approval. Ideal for busy clinical practices, specialty care providers frequently dealing with PAs, and administrative staff responsible for completing authorization requests.

Request Summary

Service/Medication requested, indication, ICD-10/CPT (if applicable), duration.

Medical Necessity

Clinical history, prior treatments tried/failed, risk of not treating, expected benefit; guidelines referenced.

Supporting Criteria Mapping

List payer criteria and indicate how patient meets each requirement with evidence.

Attachments

Clinic notes, labs/imaging, prior treatment documentation.

Administrative — Prior Authorization Template

Template

Request Summary

Medical Necessity

Supporting Criteria Mapping

Attachments

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