⚜ Prior Authorization Survival Kit ⚜
Stop Losing the Prior Auth Battle.
Twenty copy-paste AI prompts, the most common denial codes decoded, and a bulletproof PA submission checklist — built by a pharmacy tech who has lived it.
Tarean Thompson, CPhT — Certified by PTCB and NHA since 2008. This product reflects 12+ years of independent operational knowledge and is not affiliated with any certifying body.
Another denial. Another appeal. Another hour you don't have.
Insurance companies are counting on you not knowing how to fight back.
This kit exists because no one should lose a PA battle for lack of the right words.
20 AI Prompts
Copy-paste appeals for real denial scenarios. Drug class agnostic.
Denial Code Cheat Sheet
Most common codes, plain language, how to fight each one.
Bulletproof PA Checklist
Every submission requirement in order. Audit-proof.
Section 01
20 Copy-Paste AI Prompts
Drop into ChatGPT, Claude, or Gemini. Fill the brackets. Send the appeal.
Initial Appeal Letter
Write a professional prior authorization appeal letter for [MEDICATION NAME] prescribed by [DOCTOR NAME] for patient [PATIENT NAME] diagnosed with [DIAGNOSIS/ICD-10 CODE]. The insurance company denied the claim citing [DENIAL REASON]. Include medical necessity language, reference clinical guidelines, and request an expedited review.
Medical Necessity Statement
Write a medical necessity statement for [MEDICATION NAME] for a patient with [DIAGNOSIS]. Include why alternative treatments [LIST ALTERNATIVES TRIED] were ineffective or contraindicated. Use clinical language appropriate for insurance review.
Step Therapy Failure Documentation
Write a step therapy failure documentation letter explaining that the patient has already tried [MEDICATION 1] for [DURATION] and [MEDICATION 2] for [DURATION] without adequate response. Explain why [REQUESTED MEDICATION] is now medically necessary.
Peer to Peer Review Request
Draft a peer to peer review request letter from [PRESCRIBER NAME] to [INSURANCE COMPANY] requesting a clinical review of the prior authorization denial for [MEDICATION] for patient [PATIENT NAME]. Include diagnosis, clinical history, and specific request for physician reviewer contact.
Urgent / Expedited Review Request
Write an expedited prior authorization request for [MEDICATION] explaining that a standard review timeline would seriously jeopardize the patient's health or ability to regain maximum function. Patient diagnosis: [DIAGNOSIS]. Current clinical status: [SYMPTOMS/URGENCY].
Counter Non-Formulary Denial
Write an appeal for a non-formulary denial for [MEDICATION]. Explain why the formulary alternative [FORMULARY DRUG] is not appropriate for this patient due to [REASON — allergy, contraindication, prior failure]. Request formulary exception approval.
Counter Quantity Limit Denial
Write an appeal for a quantity limit denial for [MEDICATION] prescribed at [DOSE/FREQUENCY]. Explain the clinical rationale for the prescribed quantity based on the patient's [DIAGNOSIS, WEIGHT, SEVERITY, CLINICAL GUIDELINES].
Counter Frequency Limit Denial
Write an appeal for a frequency limit denial for [MEDICATION/PROCEDURE]. Explain why the prescribed frequency of [X times per Y period] is medically necessary based on the patient's condition [DIAGNOSIS] and clinical history.
Counter Not Medically Necessary Denial
Write a rebuttal to a not medically necessary denial for [MEDICATION/PROCEDURE]. Reference [CLINICAL GUIDELINE NAME] and [INSURANCE COMPANY] own coverage criteria to demonstrate that this treatment meets the definition of medical necessity for [DIAGNOSIS].
Counter Experimental / Investigational Denial
Write an appeal countering an experimental or investigational denial for [MEDICATION/TREATMENT]. Cite FDA approval status, published clinical studies, and professional society guidelines supporting use of [MEDICATION] for [DIAGNOSIS].
Patient Financial Hardship Letter
Write a patient financial hardship letter to accompany a prior authorization appeal for [MEDICATION]. The patient cannot afford the out of pocket cost of the denied alternative. Request approval of [MEDICATION] as the most cost effective medically appropriate option.
Specialty Drug Appeal
Write a prior authorization appeal for a specialty medication [MEDICATION NAME] for [DIAGNOSIS]. Include REMS program enrollment if applicable, clinical monitoring plan, prescriber specialty and experience with this medication class, and patient enrollment in manufacturer support program if applicable.
Continuity of Care Appeal
Write a continuity of care appeal for [MEDICATION] that the patient has been stable on for [DURATION] under previous insurance coverage. Explain the clinical risk of switching medications and request continuation of current therapy.
Second Level Appeal
Write a second level administrative appeal for [MEDICATION] after the first appeal was denied on [DATE]. Cite the first denial reason [REASON], explain why it is incorrect, and request independent external review if the second level appeal is also denied.
External Review Request
Write an external independent review request for [MEDICATION] denied by [INSURANCE COMPANY]. Include all prior denial dates, appeal dates, and outcomes. Request assignment to an independent review organization under state law or ERISA.
Prescriber Clinical Notes Summary
Summarize the following clinical notes [PASTE NOTES] into a clear concise prior authorization support document that demonstrates medical necessity for [MEDICATION] in language appropriate for an insurance reviewer who is not a specialist in this area.
Insurance Denial Response Script
Write a phone script for a pharmacy technician to use when calling [INSURANCE COMPANY] to follow up on a prior authorization for [MEDICATION]. Include opening, key questions to ask about denial reason and appeal process, and closing that confirms next steps and timeline.
Prior Auth Status Follow Up Email
Write a follow up email to [INSURANCE COMPANY] requesting status update on prior authorization submitted on [DATE] for [MEDICATION] for patient [PATIENT NAME] member ID [ID]. Include reference number and request response within 24 hours.
Pharmacist Clinical Justification
Write a pharmacist clinical justification statement supporting the prescriber's prior authorization request for [MEDICATION]. Include pharmacist assessment of appropriateness, therapeutic alternatives considered, and clinical outcome expectations.
Final Demand Before External Review
Write a final demand letter to [INSURANCE COMPANY] before initiating external review for denial of [MEDICATION]. State that all internal appeals have been exhausted, cite applicable state law or federal regulation requiring external review availability, and set a 5 business day response deadline.
Section 02
Denial Code Cheat Sheet
| Denial Reason | What It Means | How to Fight It |
|---|---|---|
| Not Medically Necessary | Insurance says treatment is not needed | Cite clinical guidelines and patient's specific diagnosis severity |
| Step Therapy Required | Must try cheaper drugs first | Document all prior drug failures with dates and outcomes |
| Non-Formulary | Drug not on approved list | Request formulary exception citing clinical necessity or contraindication |
| Quantity Limit Exceeded | Too much prescribed | Cite patient weight, severity, or guidelines supporting quantity |
| Frequency Limit Exceeded | Too often prescribed | Document clinical rationale based on diagnosis and treatment guidelines |
| Experimental / Investigational | Claim treatment is unproven | Cite FDA approval, published studies, professional society guidelines |
| Authorization Expired | PA ran out | Submit renewal with updated clinical notes showing continued necessity |
| Duplicate Claim | Already billed | Verify claim history and resubmit with corrected billing or appeal |
| Out of Network | Provider not in network | Request in-network exception if no in-network provider available |
| Missing Information | Incomplete submission | Identify exactly what is missing and resubmit complete package same day |
| Coordination of Benefits | Another insurer is primary | Verify COB order and resubmit to correct primary payer first |
| Prior Auth Not Obtained | PA not done in advance | Request retroactive authorization citing clinical urgency or admin error |
| Age Limit | Patient outside approved age range | Request exception with clinical justification for off-label age use |
| Gender Exclusion | Treatment not covered for gender | Cite medical necessity and request exception with clinical documentation |
| Diagnosis Not Covered | Diagnosis does not match coverage | Verify ICD-10 accuracy and appeal with additional clinical documentation |
Section 03
Bulletproof PA Checklist
⚜ Section A — Before You Submit
⚜ Section B — The Submission Package
⚜ Section C — After Submission
⚜ Section D — If Denied
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This product was created by a certified pharmacy technician with 12+ years of operational experience. It is intended for educational and operational purposes only. This material is not affiliated with, endorsed by, or approved by the Pharmacy Technician Certification Board (PTCB), the National Healthcareer Association (NHA), or the Texas State Board of Pharmacy (TSBP). CPhT is a registered trademark of the Pharmacy Technician Certification Board (PTCB). Purchase and use of this material does not guarantee employment, certification, or a passing score on any examination. This material does not constitute clinical, legal, or medical advice. Nothing in this product should be interpreted as pharmacy practice or patient care guidance.