Prior authorization letters

Build a letter of medical necessity or an appeal letter from structured clinical details, then copy it into your payer's portal or print it for fax. Free, and the patient's details never leave your browser.

Patient details stay on this device. The patient's name, date of birth, and member ID are kept in this page's memory only: they are never sent to ClinDose, saved in drafts, or included in usage data. Closing or reloading the page clears them.

Patient and plan

Patient nameDate of birthMember IDHealth planPlan fax (optional)Letter date

Medication

DrugStrengthDirectionsQuantityDuration requested

Request expedited review (urgent)

Diagnosis

Diagnosis 1

ICD-10-CM codeFills in the description when the code is in the CMS mapping table.Description

Prior therapies

List formulary or step-therapy drugs the patient already tried.

Clinical support

Contraindications to formulary alternativesClinical rationaleSupporting labs and findingsOne per line, with dates.

Guideline and literature citations

Prescriber

NameCredentialsNPIPracticeAddressPhoneFax

Keep a draft in this browser (never includes patient details)

Letter of medical necessity

Add the medication.
Add at least one diagnosis.
Add prior therapies or a clinical rationale.
Add the prescriber's name.

[Date] [Health plan] Pharmacy prior authorization department Re: Letter of medical necessity Patient: [Patient name] Date of birth: [Date of birth] Member ID: [Member ID] Medication: [Medication, strength, and directions] To whom it may concern: I am writing on behalf of my patient, [patient name], to request coverage of [medication]. Based on my clinical judgment and the information below, this medication is medically necessary for this patient. Please approve coverage of [medication] as prescribed. I am available to discuss this request, including by peer-to-peer review, at the number below. Medical records are available on request. Sincerely, [Prescriber name]

Review and edit the letter before sending. You are responsible for its clinical accuracy. Attach chart notes and lab reports the plan asks for.

The CMS prior authorization rule (CMS-0057-F)

The CMS Interoperability and Prior Authorization Final Rule was released January 17, 2024. It applies to Medicare Advantage organizations, state Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and qualified health plan issuers on the federally facilitated exchanges.

Starting January 1, 2026: decisions within 72 hours for expedited (urgent) requests and 7 calendar days for standard requests (not required of exchange plans), and a specific reason for every denial.
By March 31, 2026: payers post prior authorization metrics publicly, such as approval and denial rates and average decision times.
Starting January 1, 2027: payers run a FHIR-based Prior Authorization API, plus Provider Access and Payer-to-Payer APIs, and add prior authorization data to the Patient Access API. Clinicians in MIPS report a new Electronic Prior Authorization measure for the 2027 performance period.
Drugs are excluded. These requirements don't cover prior authorization for drugs. For Medicare Part D drug coverage determinations, existing rules already require a decision within 72 hours (standard) or 24 hours (expedited) after the plan receives the request, or, for an exception request, the prescriber's supporting statement.

Sources: CMS fact sheet, CMS-0057-F; Federal Register, 89 FR 8758 (February 8, 2024); 42 CFR 423.568 and 423.572 (Part D coverage determinations). Full electronic prior authorization runs through payer and EHR networks; ClinDose builds the letter only.