Medical Rx Prior Authorization Form Checklist: ICD-10, NDC, Labs, and Step Therapy
- Jamie P
- Sep 15
- 8 min read
Prior authorization (PA) for medications is rarely anyone’s favorite task—but when it’s clean, complete, and routed correctly on the first try, it’s the difference between a same-week pickup and weeks of back-and-forth. This guide gives you a field-tested checklist for completing any Medical Rx Prior Authorization Form in 2025, with special attention to the four items that make or break approvals: ICD-10 diagnosis, NDC or drug identifiers, required labs, and a step-therapy history that’s specific enough for reviewers to say “yes” without calling you back.
Use it as a plug-and-play SOP for clinics, or as a patient/caregiver playbook to help your prescriber submit a first-pass approval packet.
What A Medication Prior Authorization Really Asks
No matter which plan or PBM you’re dealing with, the form and portal are asking the same core questions:
Is the diagnosis clear and aligned? (ICD-10, severity, and medical necessity)
Is the drug request precise? (name, strength, form, SIG, quantity, days’ supply, NDC when asked)
Does the file prove safety and appropriateness? (required labs, contraindications, monitoring plan)
Have preferred alternatives been tried or ruled out? (step therapy with doses, dates, and outcomes)
Is there clinical risk if we wait? (justification for an expedited timeline)
If your submission hits those points on page one—and your attachments are labeled so the reviewer can find the evidence quickly—you’ve done 80% of the work.
The One-Page Intake That Saves Days
Before anyone opens a form or portal, collect this intake page. It eliminates the most common stalls:
Insurance Snapshot: Plan name, Member ID, BIN/PCN/Group (from the pharmacy card).
Preferred Pharmacy: Retail or specialty (and whether the drug is limited distribution).
ICD-10 Diagnosis: Primary code plus brief context (severity, duration, functional impact).
Medication Details: Drug name, strength, form, exact SIG, quantity, days’ supply.
Step-Therapy Grid: Prior meds in the same class or required alternatives with dose, start–stop dates, and outcome.
Required Labs/Diagnostics: Actual values + dates (not “WNL”).
Allergies/Contraindications: Especially if you’re skipping a preferred option.
Urgency Statement (if applicable): One sentence tying delay to clinical risk.
Direct Callback: A line that rings to a nurse/prescriber—no main menu.
Have patients carry a version of this to every visit; it’s the single best accelerator for first-pass approvals.
The Checklist: Exactly What To Put On The Form
Patient & Plan Details (Complete, Not Just “On File”)
Member full name, DOB, current address/phone.
Plan/Group and current pharmacy benefit (new plan years can bring new PBMs).
If the patient is stable on therapy, note continuity of therapy up front.
Prescriber & Site Information
Treating prescriber NPI, TIN, practice address, phone, fax.
Covering prescriber? Ensure documenting authority matches policy.
For shared-care situations, name the supervising specialist if relevant.
Drug Line Items (Precision Beats Guesswork)
Medication: Name + strength + dosage form (e.g., 40 mg autoinjector).
SIG: Write it out—no internal shorthand.
Quantity & Days’ Supply: Match policy; if you exceed limits (e.g., 90-day fill), give the rationale.
Refills: Add if requested; many PAs specify duration.
NDC (When Requested): Include if the form asks or if it reduces confusion for multi-source products.
ICD-10 Diagnosis (Aligned and Specific)
Primary ICD-10 that matches indication; include secondary codes that clarify severity, site, or risk (e.g., comorbidities).
One-paragraph context: baseline status, duration, functional impact (school/work/home), and precipitating factors if relevant.
Labs & Objective Evidence (Numbers + Dates)
Attach lab pages or include a concise table. Reviewers want numbers with dates, not “normal/abnormal.” Examples:
TB test: IGRA negative 04/08/2025
LFTs: ALT 22 U/L, AST 24 U/L 05/12/2025
Lipids/A1c: LDL 78 mg/dL, A1c 6.8% 05/12/2025
Disease-specific scores: e.g., PASI, CDAI, PHQ-9 with dates
If a lab is pending, state the draw date and whether therapy can safely begin.
Step Therapy (The Make-Or-Break Grid)
Create a compact, legible table. Don’t just list drug names—add dose and dates:
Drug | Dose | Start–Stop | Outcome |
Preferred Agent A | 25 mg bid | 03/2025–06/2025 | No clinical response (score unchanged) |
Preferred Agent B | 10 mg qd | 06/2025–07/2025 | Intolerable nausea (ED visit 06/28) |
Contraindication: Agent C | — | — | Documented anaphylaxis 2023 (see note) |
If requesting a non-formulary or skipping preferred steps, attach the contraindication letter or specialist recommendation.
Safety Profile & Monitoring
Co-morbidities, drug–drug interaction checks, pregnancy/breastfeeding considerations if relevant.
Monitoring plan (labs, vaccinations, infusion observation) aligned to labeling or guidelines.
Urgency (Expedited When It’s Real)
One sentence is enough: “Expedited review requested due to [specific risk without therapy], supported by [lab/value, ED visit, or documented deterioration].”
Use expedited only when criteria are met; it carries weight when used appropriately.
Signature & Direct Callback
Prescriber signature (wet or compliant e-signature).
Direct nurse/prescriber line that reaches a human—reviewers will call for clarifications.
Attachments Index (Put It On Page One)
A simple map helps reviewers find evidence fast:
Prior-medication grid
Clinic note 06/02/2025
Specialist consult 06/18/2025
Labs 05/12/2025; TB 04/08/2025
Contraindication letter 07/2023
ePA Beats Fax: Submission Channels That Actually Move
Electronic Prior Authorization (ePA) inside your EHR or through an accepted portal should be your default. Why?
Smart prompts catch missing fields (ICD-10, dose, quantity, prior meds) before submission.
Requests route to the right PBM queue automatically.
Status and approval letters return in the same system—no phone tag.
Attachments upload as labeled PDFs, keeping the packet intact.
Fax is the last resort. If you must fax, use legible print (no photos of screens), place the attachments index on page one, and call to confirm receipt and the reference number.
Timelines You Can Plan Around And How To Influence Them
Standard requests commonly run about one to two weeks when the packet is complete. Expedited cases—where delay risks serious deterioration—often finish in a few days.
You speed things up by:
Using ePA
Including all labs and the step-therapy grid on day one
Answering plan questions same-day
Ensuring the pharmacy re-adjudicates the claim immediately after approval
Remember: approval isn’t automatic pickup. Specialty logistics (stock, cold-chain shipping, signature) add 1–3 days. Call the pharmacy to close the loop.
Specialty Medications: Extra Steps, Same Fundamentals
For biologics, injectables, and limited-distribution drugs:
Expect stricter criteria and mandatory documentation of prior med failures or contraindications.
Approval letters may specify a particular specialty pharmacy. Sending to the wrong one adds days—route correctly.
Coordinate delivery windows; someone may need to sign.
If an appeal is likely or timing is tight, ask about bridge programs through the manufacturer hub.
Preventable Errors And The Fast Fix For Each
“Tried alternatives” with no dose/dates
Fix: Use the grid—drug, dose, start–stop, outcome.
Dose or quantity over plan limit
Fix: Provide weight/BSA math, titration schedule, or guideline citation.
Missing labs or “WNL”
Fix: Upload values + dates. If pending, include the draw date and safe-start plan.
Wrong channel (pharmacy vs. medical benefit)
Fix: Dispensed to patient = pharmacy (Rx PA). Clinician-administered = medical PA.
Illegible SIG or clinic shorthand
Fix: Write out the dosing instructions clearly.
Non-formulary with no exception rationale
Fix: Provide contraindication or documented failures of preferred agents.
No direct callback
Fix: Provide a number that reaches a knowledgeable human the same day.
Fax purgatory
Fix: Default to ePA/portal; if faxed, confirm receipt and reference number.
Wrong specialty pharmacy
Fix: Follow the approval letter; re-send immediately if misrouted.
No attachments index
Fix: Add a one-page map so reviewers see the complete packet at a glance.
Patient & Caregiver Playbook
Bring a one-page med history (drug, dose, start–stop dates, outcome).
Carry your current insurance card—BIN/PCN can change with plan year.
Ask your clinic to submit via ePA and attach labs/notes with the first pass.
Get the reference number and the decision window; save both.
After approval, call the pharmacy to ensure the claim re-billed and to check stock/shipping.
If denied, ask for the exact reason and appeal timeline; request an expedited appeal when clinically appropriate.
Clinic SOP You Can Drop Into Your Workflow
Intake (Front Desk or MA):
Capture insurance (Member ID + BIN/PCN/Group) and preferred pharmacy
Start the step-therapy grid with dose and dates
Request recent labs; schedule draws if missing
Submission (Nurse or Coordinator):
Use ePA/portal; avoid fax if possible
Attach progress note, specialist letter, lab PDFs, step-therapy grid
Include a one-line urgency only when criteria are met
Provide a direct callback number that reaches clinical staff
Tracking (Coordinator):
Log submission date, reference #, and decision window
Check 48–72 hours (expedited) or day 7–10 (standard)
Document who you spoke with and what they requested
Closure (Coordinator):
Forward the approval letter to pharmacy and patient
Confirm re-adjudication and stock/shipping
If denied, file a targeted appeal the same day (see template below)
Denials: Use The Letter As A To-Do List
A denial isn’t a dead end; it’s a checklist of the exact criteria not met.
Paste the denial reason at the top of your appeal.
Target the gap: add missing labs, correct the dose, extend the step-therapy grid with doses/dates/outcomes, or include the specialist’s note.
Request expedited appeal if delay risks harm (and say why).
Ask for peer-to-peer and prepare a 90-second evidence pitch that mirrors policy language.
Continuity of therapy: If the patient was already stable on the med before a formulary change, request coverage to avoid harm from switching.
Appeal Template:
Denial cites criterion [X]. Attached are [labs with dates], [prior-med grid with doses/dates/outcomes], and [specialist note dated ___]. The member meets policy requirements for [indication]. Given [specific risk], we request expedited approval.
Practical Scenarios So You Can Sanity-Check Your Packet
Scenario A: Straightforward Step-Therapy Case
You include a grid with two preferred agents tried at therapeutic doses, with start–stop dates and measured outcomes.
Labs meet the policy. Dosing is within limits.
Likely path: approval in a few days (expedited) or within one week (standard), then pharmacy re-bill and pickup.
Scenario B: High-Dose Request Over Quantity Limit
You attach weight/BSA math and a titration plan, plus specialist rationale.
You add a one-line urgency due to risk of hospitalization if undertreated.
Likely path: medical review asks one clarification, then approves with limits.
Scenario C: Non-Formulary With Contraindication
You provide a contraindication letter and ED documentation, plus a short note explaining risk with preferred agents.
Likely path: exception approval; ensure the pharmacy has the exact NDC if required.
How To Keep Everything Audit-Ready Without Extra Work
Name files clearly: MemberID_Drug_RequestDate_Labs.pdf
Version control: Date-stamp grids and summaries; replace prior versions rather than stacking.
Central notes: Keep the step-therapy grid in a shared folder and update per visit.
Monthly spot checks: Pull two recent cases; confirm that each includes ICD-10, NDC/drug specifics, lab values with dates, and complete step-therapy details.
Patient & Clinic Scripts
Patient → Clinic (Day 0–1): “Hi, the pharmacy says my prescription for [Drug] needs prior authorization. Could you submit it electronically and include my prior meds with doses/dates plus any required labs? I can email my med history today. Please call back with the reference number.”
Clinic → Plan/PBM (Expedited, Day 2): “This is [Clinic] about member [ID] and [Drug]. We submitted electronically on [date] with chart notes and prior-med history. We’re requesting expedited review due to [specific risk]. Is any specific criterion still needed to finalize today?”
Patient → Pharmacy (After Approval): “We just received approval for [Drug]. Could you re-adjudicate the claim today and let me know if it’s in stock—or when shipment is scheduled?”
The Bottom Line
Fast approvals aren’t luck. They come from front-loading evidence and using the right channel. Put ICD-10 on page one with a plain-language diagnosis, include the NDC/drug specifics and a clear SIG, attach lab values with dates, and build a step-therapy grid with doses and start–stop dates—not vague “tried/failed” notes. Submit via ePA, keep a direct callback handy, and close the loop with a pharmacy re-bill the moment the letter arrives. Do that, and “PA pending” turns into “Approved—ready for pickup” far more often and far faster.
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