Insurance Authorization Tracking Log

Per-patient log for tracking insurance authorization requests, payer response times, denial outcomes, and follow-up actions.

Patient and Request Details

• Patient Identifier
  Use your internal patient ID or medical record number. Avoid collecting SSN or full DOB unless specifically required.
• Patient Name
  Enter the patient name only if needed for internal tracking.
• Date Authorization Request Was Submitted
• Request Type
• Service Category
• Service or Procedure Description
  Briefly describe the requested service using the minimum necessary detail.

Payer and Authorization Information

• Payer Name
• Plan Type
• Authorization Reference Number
  Enter the payer reference number if one was assigned.
• Submission Method
• Submitted By
  Optional internal staff name or role for audit trail.

Payer Response and Status

• Current Status
• Payer Response Date
• Response Time in Days
  Number of calendar days between submission and payer response.
• Decision Summary
  Summarize the payer response, approval limits, or denial rationale.
• Denial Reason

Follow-Up and Appeal Actions

• Follow-Up Required?
  Check if any action is still needed after the payer response.
• Follow-Up Action
• Follow-Up Due Date
• Appeal Filed?
• Follow-Up Notes
  Add concise notes about calls, documentation sent, escalation, or closure status.

Consent and Submission

• PHI Acknowledgement
  I confirm this entry contains only the minimum necessary PHI needed for authorization tracking and case management.
• Consent to Store Record
  I understand this submission will be stored in the authorization log for audit trail and follow-up purposes.
• Submission Notes
  Optional notes for the reviewer.