Prior Authorization / Retroactive Authorization Appeal Letter

Use this when the payer denied for a missing authorization. The strongest versions either produce an auth number the payer failed to link, show auth wasn't required, or request a retro-auth on an emergent or add-on service backed by medical necessity.

What makes it win

• If an authorization exists, lead with the auth number and tie it to the exact claim and dates
• If the service was emergent or an intraoperative add-on, argue prospective auth was not clinically feasible
• Request retroactive authorization under the payer's retro-auth policy, supported by the clinical record
• If auth wasn't required for the code/plan, cite the payer's own list showing it

The template

Replace the [BRACKETED] fields with your details. This is the manual version of the appeal Volari files for you automatically.

[PRACTICE LETTERHEAD]
[DATE]

[PAYER NAME] — Appeals Department
[PAYER APPEALS ADDRESS]

RE: Appeal of Prior Authorization Denial (CARC 197)
Patient: [PATIENT NAME]   Member ID: [MEMBER ID]
Claim #: [CLAIM NUMBER]   Date(s) of Service: [DOS]
CPT/HCPCS: [CPT CODE]

To the Appeals Department:

We are appealing the denial of [CPT CODE] for absent prior authorization and request [reconsideration / retroactive authorization].

[IF AUTH EXISTS: Authorization #[AUTH NUMBER] was issued on [DATE] for this service and patient but was not matched to the claim. We ask that the claim be reprocessed against this authorization.]

[IF EMERGENT/ADD-ON: This service was [emergent / an intraoperative finding] and prospective authorization was not clinically feasible. [DESCRIBE CLINICAL CIRCUMSTANCE]. Under [PAYER]'s retroactive authorization policy, we request retro-auth based on the enclosed record.]

The service was medically necessary: [BRIEF CLINICAL JUSTIFICATION AND FINDINGS]. Delaying care to obtain authorization would have been inappropriate given [REASON].

Enclosed: [operative/office note dated DATE], [auth documentation, if any].

We request the denial be overturned and the claim paid. Please reach [CONTACT NAME] at [PHONE].

Sincerely,
[BILLING MANAGER NAME], [TITLE]
[PRACTICE NAME] — NPI [NPI]   TIN [TIN]

Common questions

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