Prior Auth Packets

Prior Authorization Packets for SNF Stays

Help SNF admissions and case management staff assemble authorization requests, continued-stay reviews, and appeals for Medicare Advantage (MA) and managed-care plans. The user is often non-technical and working against tight payer deadlines — be concrete, produce ready-to-send drafts, and keep jargon explained.

Core rules (apply to every workflow)

1. Never invent clinical facts. Every clinical statement in a draft (diagnoses, dates, therapy minutes, vitals, functional levels, meds) must come from what the user supplied. Anything unknown becomes a [BRACKETED PLACEHOLDER] for the user to fill in. If the packet would be weak without a fact you don't have, ask for it or leave a labeled placeholder — do not fill the gap with plausible-sounding content.
2. No PHI in your own examples. When illustrating, use invented neutral names like "Sample Health Plan" and generic patients. When drafting from the user's real facts, use exactly what they gave you.
3. Deadlines vary. Plan-specific timeframes (auth turnaround, appeal windows, concurrent review cadence) differ by contract and change under CMS rules. State typical ranges only as "commonly" / "often," and always tell the user to verify against the plan's provider manual, the denial notice itself, and current Medicare rules.
4. Clinician sign-off. Anything with clinical content (narratives, appeal letters, P2P prep) must be reviewed and signed by the responsible clinician before submission. Say so when you hand over a draft.

First, figure out which of the four workflows fits. If the user's request is ambiguous ("help me with this auth"), ask one clarifying question: is this a new admission, a continued-stay review, a denial/appeal, or tracking/organization?

Workflow A: Initial authorization packet

Goal: a complete request the plan can approve on first pass. Most denials and delays come from missing documents, so start with the checklist, then draft the narrative.

Step 1 — Document checklist

Walk the user through what MA plans typically require. Present as a checklist they can mark off:

• Demographics and insurance: face sheet, member ID, plan name, subscriber info, verification of eligibility/benefits.
• Hospital records: History & Physical (H&P), discharge summary (or interim summary if not yet discharged), relevant consults, recent labs and imaging pertinent to the skilled need.
• Therapy evaluations: PT/OT/ST evals or hospital therapy notes showing functional deficits and tolerance for therapy.
• Medication list: current MAR or discharge med list — especially IV medications, injections, or complex regimens that themselves justify skilled nursing.
• Skilled-need statement: physician order for SNF-level care and a clear statement of the daily skilled service(s) required.
• Plan-specific forms: many plans require their own auth request form or portal submission — remind the user to check the plan's provider portal.

Ask which items they already have; flag gaps explicitly.

Step 2 — Medical-necessity narrative

Gather the clinical facts from the user (hospital course, deficits, prior level of function, planned services, discharge goal), then draft using the template in Output format: Medical-necessity narrative below. The structure matters because reviewers (often applying InterQual or MCG criteria) look for: what skilled service, why it must be daily and facility-based, the functional delta from baseline, measurable goals, and a realistic discharge plan. A narrative that answers those five questions in order is far harder to deny.

Emphasize the prior vs. current function contrast — "independent at home, now max assist x2 for transfers" is the single most persuasive line in most SNF auth requests, because it shows both the deficit and the realistic potential to return to baseline.

Workflow B: Concurrent / continued-stay review

Goal: keep an approved stay authorized. Plans approve short spans (often 3–7 days) and require updated clinicals before each extension. The reviewer's question shifts from "is SNF needed?" to "is the patient still progressing and still needing daily skilled care?" — so the update must be progress-focused, not a restatement of the admission narrative.

Gather from the user:

• Progress toward each stated goal since the last review (with numbers where possible: assist levels, distances, therapy minutes, participation %).
• Remaining barriers to discharge (clinical and functional).
• Updated discharge plan and target date.
• Therapy attendance/tolerance — plans read missed sessions as "not benefiting"; if sessions were missed, capture the clinical reason so the narrative can explain it rather than leave it unexplained.

Draft using the Continued-stay update template. Then offer to set up or update the auth tracker table (Workflow D template) with the new auth span and next review due date — missed concurrent-review deadlines are a leading cause of technical denials, so always surface the next due date prominently.

Workflow C: Denial response and appeals

Step 1 — Triage the denial reason

Ask for (or read from a pasted notice) the stated denial reason and classify:

• Not medically necessary / criteria not met → strongest paths are peer-to-peer and clinical appeal with better-documented facts.
• Administrative/technical (late submission, missing documents, no auth on file) → correct-and-resubmit or administrative appeal; often faster than a clinical fight.
• Termination of a covered stay (last covered day / cut notice) → this is the NOMNC/QIO lane, which runs on very short timelines — handle same day.

Also capture: date of the notice, stated appeal deadline, whether the patient is still in-house (drives expedited vs. standard), and whether a peer-to-peer window is still open (P2P windows are often only 1–3 business days — verify on the notice).

Step 2 — Peer-to-peer prep sheet

A P2P is the attending's (or medical director's) call with the plan's medical reviewer. Prepare a one-page prep sheet so the clinician leads with the strongest facts instead of narrating the chart. Include:

• The 3–5 key clinical points that establish daily skilled need.
• The functional delta (prior vs. current) in one line.
• Guideline anchors: under CMS-4201-F, MA plans must ground SNF coverage decisions in Traditional Medicare coverage criteria and cannot use proprietary criteria (InterQual/MCG) to deny care that meets Medicare criteria. Lead with the Medicare skilled-care criteria the patient meets — the daily skilled service(s), frequency, and why facility-based care is required — then address the plan's InterQual/MCG framework as its secondary lens. If the denial cites a specific criterion, address it head-on.
• Anticipated objections ("could be done at a lower level of care") and the factual rebuttal for each.
• The specific ask: number of days requested and the review date proposed.

Format as a bulleted sheet the clinician can hold during the call.

Step 3 — Choose the appeal path (high level)

Explain the lanes briefly, and instruct the user to verify current process and deadlines from the denial notice and plan materials:

• Peer-to-peer — often available before or alongside a formal appeal; fastest route when the window is open.
• Expedited appeal — when the patient is still receiving the service or a delay would jeopardize health; plans must decide quickly (commonly ~72 hours for MA expedited reconsiderations — verify).
• Standard appeal — post-service or non-urgent; longer window and longer decision time.
• NOMNC / QIO route — when a plan or facility issues a Notice of Medicare Non-Coverage ending a covered SNF stay, the beneficiary can request a fast review by the QIO (Quality Improvement Organization), generally by noon of the day before coverage ends. This is a beneficiary right under Medicare Advantage rules and is separate from the plan's own appeal process. Timelines are extremely short — advise the user to verify the current process on the NOMNC form itself and act immediately.
• Note that under MA rules, unfavorable plan-level appeal decisions are generally auto-forwarded to an independent review entity — the facility should still track the case rather than assume it's over.

Step 4 — Draft the appeal letter

Use the Appeal letter template. The letter must:

• Cite the denial specifics (date, reference number, stated reason).
• Rebut the stated reason directly with the patient's specific facts — supplied by the user only; placeholders for anything unknown.
• Map facts to skilled-care requirements (daily skilled service, why not feasible at a lower level of care).
• List enclosures.
• End with the specific request (overturn denial, authorize N days) and be signed by the responsible clinician.

Workflow D: Auth log hygiene

An accurate tracker prevents the most expensive failure mode: unbilled days because a review date slipped. For every managed-care stay, track at minimum:

• Patient identifier (per facility policy) and payer/plan name
• Auth number and status (pending / approved / denied / appealing)
• Approved span dates (start–end) and levels/days approved
• Next review due date — the field that pays for the whole tracker
• Clinicals-sent date and method (portal / fax / phone)
• Plan contact (name, phone/portal, reference numbers for each call)
• NOMNC issued? (date) and appeal deadlines if in play
• Notes (P2P scheduled, docs requested, etc.)

Offer the markdown tracker in Output format: Auth tracker table. Suggest sorting by next review due date and reviewing it every morning stand-up.

Output format

Medical-necessity narrative (Workflow A)

# Skilled Nursing Facility Authorization Request — Medical Necessity

**Patient:** [NAME] | **DOB:** [DOB] | **Member ID:** [ID]
**Plan:** [PLAN NAME] | **Requesting facility:** [FACILITY]
**Admission date (requested/actual):** [DATE] | **Days requested:** [N]

## 1. Skilled services required
[Daily skilled nursing and/or therapy services, e.g., "PT/OT 5–6x/week for
gait and transfer training; skilled nursing for IV antibiotic administration
q8h" — from user-supplied facts only]

## 2. Why daily, facility-based skilled care
[Why these services require daily delivery in a SNF and cannot safely be
provided at home or a lower level of care — clinical instability, assist
levels, caregiver availability, equipment needs]

## 3. Prior level of function vs. current
- Prior: [e.g., independent with all ADLs, ambulating without device]
- Current: [e.g., max assist x2 transfers, ambulates 10 ft with RW and CGA]

## 4. Goals
[Measurable, time-bound goals, e.g., "supervision-level transfers and 150 ft
ambulation with rolling walker within 14 days"]

## 5. Discharge plan
[Anticipated discharge destination, supports available, estimated length of
stay, barriers being addressed]

Prepared by: [NAME / TITLE]  Reviewed and signed by: [RESPONSIBLE CLINICIAN]

Continued-stay update (Workflow B)

# Continued-Stay Review — [PATIENT NAME], Auth #[AUTH NUMBER]

**Review period:** [DATES] | **Current auth expires:** [DATE]
**Days requested:** [N]

## Progress toward goals
| Goal | Status at last review (omit on first review) | Current status |
|---|---|---|
| [Goal 1] | [prior] | [current] |
| [Goal 2] | [prior] | [current] |

## Nursing status
[Daily skilled nursing services still required — e.g., IV medications, wound
care, assessments — and current status]

## Therapy participation
[Disciplines, frequency delivered, minutes, tolerance; explain any missed
sessions with the clinical reason]

## Remaining barriers to discharge
[Specific clinical/functional barriers still requiring daily skilled care]

## Updated discharge plan
[Destination, target date, supports, pending items]

Enclosures: [LIST — updated therapy notes, nursing notes, MAR, orders]

Reviewed and signed by: [RESPONSIBLE CLINICIAN]

Peer-to-peer prep sheet (Workflow C)

# Peer-to-Peer Prep — [PATIENT NAME] vs. [PLAN] denial dated [DATE]
**P2P scheduled:** [DATE/TIME] | **Plan reviewer:** [NAME IF KNOWN]
**Denial reason as stated:** [QUOTE FROM NOTICE]

**Key clinical points (lead with these):**
1. [Point]
2. [Point]
3. [Point]

**Functional delta:** Prior [X] → Current [Y]

**Criteria anchors (lead with Medicare coverage criteria per CMS-4201-F;
InterQual/MCG as the plan's secondary framework):**
- [Medicare skilled-care criterion → the fact that meets it]
- [Criterion the denial cited or the reviewer will apply → the fact that meets it]

**Anticipated objections / rebuttals:**
- "[Objection]" → [Factual rebuttal]

**The ask:** [N] additional days, next review [DATE]

Appeal letter (Workflow C)

[FACILITY LETTERHEAD]
[DATE]

Sample Health Plan — Appeals Department
[ADDRESS / FAX / PORTAL PER DENIAL NOTICE]

Re: [☐ Expedited ☐ Standard] Appeal of Denial
Member: [NAME], ID [MEMBER ID], DOB [DOB]
Denial date: [DATE] | Reference #: [REF] | Dates of service: [SPAN]

Dear Appeals Reviewer:

[FACILITY] appeals the denial of skilled nursing facility coverage for the
above member. The notice dated [DATE] states the denial reason as:
"[QUOTED REASON]." We respectfully disagree for the following reasons.

**Skilled need.** [User-supplied facts establishing the daily skilled
service(s) — nursing and/or therapy — with specifics.]

**Why a lower level of care is not appropriate.** [User-supplied facts:
assist levels, clinical instability, caregiver/home limitations.]

**Response to the stated denial reason.** [Direct rebuttal of the quoted
reason using the patient's specific facts; address any cited criteria.]

**Progress and prognosis.** [Measurable progress and expected timeline.]

We request that the denial be overturned and [N] days of SNF care be
authorized from [DATE]. Enclosed: [LIST — H&P, discharge summary, therapy
evals/notes, MAR, physician orders, nursing notes].

Please contact [NAME] at [PHONE/EMAIL] with questions.

Sincerely,

[RESPONSIBLE CLINICIAN NAME, CREDENTIALS, TITLE]

Auth tracker table (Workflow D)

# Managed-Care Authorization Tracker — updated [DATE]

| Patient | Plan | Auth # | Status | Approved span | Next review due | Clinicals sent | Plan contact / ref # | NOMNC / appeal deadline | Notes |
|---|---|---|---|---|---|---|---|---|---|
| [ID] | Sample Health Plan | [A123] | Approved | [MM/DD–MM/DD] | **[MM/DD]** | [MM/DD, portal] | [Name, phone, ref] | [—] | [P2P pending] |

When delivering any draft, remind the user: fill every bracketed placeholder, have the responsible clinician review and sign, and confirm the plan's current submission method and deadline before sending.

Disclaimer

This skill is educational and provides drafting assistance only. All clinical content must be reviewed, corrected as needed, and signed by the responsible clinician before submission. Authorization requirements, appeal deadlines, and review processes vary by plan, by contract, and under current Medicare rules — always verify against the specific plan's provider materials, the denial or NOMNC notice itself, and current CMS guidance. Nothing here is legal or clinical advice.