Prior Authorization Request and Tracking Log

Track prior authorization requests by payer, status, approval details, visit limits, and authorization numbers to reduce claim denials and missed renewals.

Request Details

• Request Date
  Date the prior authorization request was submitted to the payer.
• Patient Identifier
  Use the internal patient ID or medical record number. Do not enter SSN or other unnecessary PII.
• Payer Name
  Name of the insurance payer or plan.
• Service Requested
  Brief description of the procedure, visit, medication, or service requiring authorization.
• Request Type

Authorization Status

• Current Status
• Submission Method
• Payer Reference Number
  Reference or case number assigned by the payer.
• Turnaround Time (Days)
  Number of days from submission to payer decision or current status update.
• Follow-Up Due Date
  Next date to contact the payer if no decision has been received.

Approval and Visit Limits

• Authorization Number
  Authorization number issued by the payer.
• Approval Date
  Date the payer approved the request.
• Effective Start Date
  Start date for the approved authorization period.
• Effective End Date
  End date for the approved authorization period.
• Visit Limit
  Maximum number of visits, units, or occurrences authorized.
• Limit Unit

Denial and Follow-Up

• Denial Reason
  Brief payer-provided reason for denial or partial denial.
• Appeal Required?
  Select if the denial will be appealed.
• Appeal Due Date
  Deadline to submit the appeal, if applicable.
• Follow-Up Action
• Notes
  Operational notes, call outcomes, or documentation reminders.

Submission and Audit Trail

• Submitted By
  Name or team responsible for the submission.
• Last Updated
  Timestamp of the most recent status update.
• Internal Reference
  Optional internal tracking number or case reference.