Prior Authorization Claim Processing Timeline Tracker Form
Track prior authorization claim milestones, status changes, delays, and follow-up actions from submission through resolution.
Claim & Member Details
Claim/Reference Number
*
Member/Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Payer/Insurance Company Name
*
Plan Type
*
Commercial
Medicare
Medicaid
Employer-Sponsored
Other
Provider/Facility Name
*
Provider Contact Person
Authorization Timeline Tracking
Authorization request submission date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date received by payer
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supporting documents sent date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Initial review start date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Decision date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Effective/expiration date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current status
*
Not submitted
Submitted
Under review
Pending additional information
Approved
Denied
Appealed
Closed
Turnaround time (days)
Decision, Delays & Follow-Up
Decision Outcome
*
Approved
Denied
Partially Approved
Pending
Withdrawn
Escalated
Denial or Delay Reason
Additional Information Requested
Escalation Status
Please Select
None
Nurse Reviewer
Peer-to-Peer Review
Supervisor Review
External Appeal
Next Follow-Up Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Owner / Assignee for Follow-Up
Notes / Comments
Submit Tracker
Should be Empty: