What goes in a prior authorization packet
A prior authorization packet is the set of information you send a payer so it can decide on a planned service. Payers differ in forms and portals, but most reviewers look for the same building blocks. Use this as a checklist, then check the payer's own requirements.
Updated · Markdown version
The checklist
| Part | What to include |
|---|---|
| Patient and coverage | Name, date of birth and member ID exactly as on the insurance card, plus group or plan details if the payer asks. |
| Requesting provider | Name, practice, NPI and contact details for questions from the reviewer. |
| Procedure codes | The code for each planned service (for example CDT for dental, CPT or HCPCS for medical services), with quantity or number of visits where relevant. |
| Diagnosis codes | ICD-10-CM codes that support the service, matching what your notes say. |
| Clinical justification | Why this service is needed for this patient: findings, severity, functional impact and what makes alternatives unsuitable. |
| Treatment history | What has already been tried, for how long, and with what result. |
| Supporting documents | Chart notes, imaging, photographs, measurements or outcome scores the payer's criteria ask for. |
| Request letter | A short, specific letter to the reviewer summarizing the request and pointing to the evidence. |
Writing the clinical justification
- State the finding and the patient's problem in the first sentences.
- Give the objective evidence: measurements, imaging results, dates.
- Say what was tried before and why it was not enough.
- Explain why the requested service, and not a cheaper alternative, is appropriate.
- Keep every statement traceable to something in the chart. Do not add facts the notes do not support.
Common reasons a request comes back
- A document the payer's criteria call for is missing, such as a pre-operative image or an outcome score.
- The codes and the narrative do not agree.
- Identifiers do not match the insurance record.
- The justification says the service is needed but not why alternatives will not work.
- The request went to the wrong channel, or after a deadline.
How Genko Prior Auth uses this structure
Prior Auth drafts three sections from your notes and structured findings: a clinical justification, a supporting-documentation summary and a request letter. It also lists what the payer may expect that you have not provided. Your team edits every section, locks the packet and exports a PDF; you submit it through the payer's own channel.
See Generating a packet and Review and lock.