Prior Authorization Records
What should I know about prior authorization records: request and appeal guide?
Learn how to request prior authorization records from your insurance company. Guide covers accessing approval/denial letters, appeal documentation, and medical necessity records.
When your insurance denies a treatment, the denial letter is the starting point—not the whole story. The prior authorization file contains what they actually reviewed, what criteria they used, and who made the call. You have the right to all of it.
What is Prior Authorization?
Prior authorization is your insurance company's checkpoint before it agrees to pay. Your doctor requests approval for a medication or procedure. The insurer reviews it against their criteria and says yes or no. When they say no, you're entitled to see exactly why—and the full file they used to make that decision.
Medications
Brand-name drugs, specialty medications, high-cost prescriptions
Procedures
Surgeries, imaging (MRI, CT), physical therapy, hospital admissions
Equipment
Durable medical equipment, prosthetics, specialized devices
What's in Prior Authorization Records?
The full prior authorization file is more than a denial letter. Here's what it contains:
Prior Authorization Request
The original request submitted by your healthcare provider
Clinical Documentation
Medical records submitted to support the request
Decision Letter
The approval or denial notification
Clinical Criteria
Guidelines used to evaluate the request
Reviewer Notes
Documentation of the review process
Appeal Records
Documentation from any appeals
How to Request Prior Authorization Records
1Contact Your Insurance Company
Call the member services number on your card. Be specific—vague requests get vague results:
- •Ask for copies of all prior authorization records
- •Specify the treatment, medication, or procedure
- •Request all supporting documentation submitted
- •Ask for the clinical criteria used for the decision
2Submit Written Request
Phone calls don't create paper trails. Follow up in writing:
- •Include your name, member ID, and date of birth
- •Specify what records you're requesting
- •Reference the prior authorization number if known
- •Send via certified mail with return receipt
Tip: For employer-sponsored plans (ERISA), specifically request "all documents, records, and other information relevant to your claim" - this is language from federal law that ensures you get everything.
3Check Your Online Portal
While waiting for the written response, check your member portal. It may already have what you need:
- •Log into your member portal
- •Look for "Prior Authorizations" or "Pre-certifications" section
- •Download decision letters and reference numbers
- •Note: Portal may not have complete clinical documentation
4Request from Your Provider
Your doctor submitted the original request and has a copy. Ask for theirs too—sometimes it includes communications the insurer won't volunteer:
- •Copies of the prior authorization request they submitted
- •Clinical documentation and letters of medical necessity
- •Communications with the insurance company
- •Peer-to-peer call notes between your doctor and insurer
Your Rights to Prior Authorization Records
ERISA Rights (Employer Plans)
If you have insurance through your employer, ERISA (Employee Retirement Income Security Act) gives you the right to receive all documents, records, and information relevant to your claim. The plan must provide these within 30 days of your request.
State Insurance Law Rights
For individual/marketplace plans and state-regulated insurance, state laws generally require insurers to provide claim file access. Timeframes vary by state but typically allow 30 days to respond.
Right to Clinical Criteria
You have the right to know what criteria the insurer used to make their decision. This includes their medical policies, clinical guidelines, and coverage criteria. This information is essential for understanding denials and preparing appeals.
No Surprises Act Rights
The No Surprises Act (2022) requires insurers to provide advance explanation of benefits (EOB) before scheduled services, including information about prior authorization requirements and estimated costs.
Using Records for Appeals
A denial is not final. The records you request are your ammunition for the appeal:
Understanding the Denial
Read the denial carefully. Most are vague on purpose. The records tell you what they actually relied on:
- •Specific reason: What criteria wasn't met?
- •Clinical criteria: What guidelines were used?
- •Reviewer credentials: Who reviewed the request?
- •Missing information: What documentation was lacking?
Building Your Appeal
A strong appeal is specific. Respond to each denial reason with direct evidence:
- •Address each denial reason with specific documentation
- •Show how you meet the clinical criteria they cited
- •Include additional medical records supporting necessity
- •Get a detailed letter from your doctor
Appeal Deadlines
Miss the deadline and you lose your right to appeal. Don't wait:
- ⚠️Internal appeal: Usually 180 days from denial
- ⚠️External review: Varies by state, often 4 months from final internal denial
- ⚠️Expedited appeal: Available for urgent situations
External Review
If the internal appeal fails, external review is where insurers often lose. An independent reviewer—not an insurer employee—decides:
- •Independent reviewers examine your case
- •Request complete claim file before review
- •External decision is usually binding on the insurer
- •Available for denials based on medical necessity
Keeping Your Prior Auth Records
Don't depend on the insurer's records alone. Maintain your own file from the start:
What to Save
- •All approval/denial letters
- •Prior authorization numbers
- •Dates of requests and decisions
- •Names of representatives you spoke with
- •Appeal correspondence
Why This Matters
- •Prove approval if claims are denied
- •Support appeals of later denials
- •Track patterns for ongoing conditions
- •Evidence for complaints or lawsuits
- •Transfer information to new providers
See our guide: How to Organize Medical Records
Frequently Asked Questions
How do I get copies of my prior authorization records?
Call member services and ask for the complete prior authorization file—the original request, all supporting documentation, the decision letter, and the clinical criteria used. Then follow up in writing. Phone calls get forgotten; written requests create a deadline.
What is included in prior authorization records?
The file typically includes your provider's original request, the clinical documentation they submitted (records, test results, letter of medical necessity), the insurer's decision letter, the criteria they used, reviewer notes, and any appeal correspondence. The criteria document is often the most useful piece for building an appeal.
Can insurance companies deny access to prior authorization records?
No. Under ERISA (for employer plans) and state insurance laws, you have the right to your complete claim file, including all prior authorization records. If they refuse, cite your legal rights in writing. Refusal is itself a violation you can report to your state insurance commissioner.
Related Guides
Fighting a Prior Authorization Denial?
The records are the appeal. We help you get them from your provider, your insurer, and anywhere else they live.