Prior Authorization Denial Rate Tracking Form
Track and review prior authorization denial rates and related operational data for healthcare teams.
Reporting Period
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submitting Department or Team
*
Please Select
Billing
Patient Access
Medical Records
Utilization Management
Revenue Cycle
Other
Payer
*
Please Select
Aetna
Blue Cross Blue Shield
Cigna
Medicare
Medicaid
UnitedHealthcare
Other
Total Prior Authorization Requests Submitted
*
Total Denials Received
*
Denial Rate (%)
Top Denial Reasons
*
Medical Necessity
Incomplete Documentation
Non-Covered Service
Authorization Not Obtained
Eligibility Issue
Other
Service or Category Affected
*
Inpatient
Outpatient
Surgery
Imaging
Lab
Therapy
Other
Follow-up Actions Taken
*
Appeal Submitted
Peer-to-Peer Review
Documentation Updated
Claim Resubmitted
No Action
Other
Escalation Status
*
Escalated to Management
In Progress
Resolved
Not Escalated
Additional Notes or Comments
Submit Report
Should be Empty: