Prior-Authorization & Appeal Scripts

The caregiver is on the phone, but the insurer refuses to speak to them because no written CMS-1696 or HIPAA release is on file yet. Conference the patient onto the line and have them read the script verbatim. The representative notes consent in the file for the duration of this call only.

"My name is [Patient Name], my date of birth is [DOB], and my ZIP code is [ZIP]. I am providing verbal authorization for my [Relation], [Caregiver Name], to act as my designated representative for the duration of this call. They are authorized to discuss my protected health information, claim status, and denial reasons regarding my [Condition / Medication]. Please note this verbal consent in my file and speak directly with them."

EviCore or the primary insurer denied an MRI citing "alternative treatment should be tried first." You are calling to schedule the P2P between the treating physician and the insurer's medical director. Use the number on the denial letter, not the back of the insurance card — for Cigna and Humana specialty imaging that number routes to EviCore, not the insurer.

"I am calling to formally request a peer-to-peer review for authorization number [Auth Number] regarding member [Member ID], which was denied for lack of medical necessity. My physician's direct line is [Phone Number], and they have the patient's clinical records demonstrating they have already exhausted six weeks of conservative PT therapy, which meets the criteria in your Medical Coverage Policy. Please provide the available time slots to speak with an [Orthopedic / Neurology] medical director."

Pallie can schedule the P2P and absorb the hold time. The peer-to-peer conversation itself is physician-to-physician by law — your doctor speaks to the medical director.

The insurer is demanding the patient fail a cheaper drug before authorizing a biologic. The lever is a documented clinical contraindication to the preferred drug — the physician must be ready to fax the supporting note on the same call.

"I am calling to initiate a step-therapy exception request for [Drug Name]. The denial states the patient must try [Cheaper Drug A] first. However, the patient has a documented clinical contraindication to [Cheaper Drug A] due to their history of [Comorbidity]. Forcing them to take this medication would result in an adverse reaction. I need to escalate this to an expedited clinical review, as any delay in initiating [Drug B] threatens to severely destabilize their condition. What fax number should the provider use to send the specific contraindication documentation?"

Your denial landed fast — sometimes seconds — and reads like a template. If the plan is issued in California, Arizona, Maryland, or another state with a 2024–2026 AI-denial statute, you have a clean procedural lever. Demand written confirmation that a licensed physician reviewed the case. If they cannot produce it, the denial is procedurally defective.

"I am appealing denial reference [Reference Number]. Under [California SB 1120 / Arizona HB 2175 / Maryland HB 820], health plans are strictly prohibited from denying care based solely on an artificial intelligence algorithm. I am officially requesting written confirmation that a licensed physician, who is competent to evaluate this specific clinical issue, independently reviewed my medical records before issuing this denial. If this denial was generated automatically, I demand an immediate reversal and human review."

The insurer is capping psychotherapy visits, imposing concurrent-review hurdles, or suppressing out-of-network reimbursement for behavioral health in ways it does not apply to medical/surgical care. Under the 2024 MHPAEA final rules this is a non-quantitative-treatment-limit (NQTL) violation and files directly with the Department of Labor.

"I am calling to contest the visit limitation on this behavioral health claim. Under the Mental Health Parity and Addiction Equity Act, and specifically the 2024 final rules, you cannot impose greater Non-Quantitative Treatment Limits on mental health services than you do on medical services. Capping these visits when you do not apply similar caps to primary care visits is a compliance violation. I am escalating this to a formal appeal and will concurrently copy the State Department of Insurance and the Department of Labor on my written submission."

The patient went to the nearest ER during a crisis; the insurer denied the claim as out-of-network. The federal No Surprises Act requires emergency services to be covered at in-network cost-sharing regardless of facility network status, and prior authorization is not required.

"I am calling regarding claim [Claim Number]. This was a true medical emergency, and the patient was transported to the nearest facility capable of stabilizing them. Under the federal No Surprises Act, emergency services must be covered at the in-network cost-sharing rate, regardless of the facility's network status, and prior authorization is not required. I request this claim be reprocessed immediately under the emergency services mandate."

The insurer retrospectively decided the ER visit wasn't a true emergency based on the final diagnosis. The lever is the prudent-layperson standard — emergency coverage is triggered by the patient's presenting symptoms, not by what the diagnosis turned out to be.

"I am appealing the downcoding of claim [Claim Number]. The prudent layperson standard dictates that emergency coverage must be based on the patient's presenting symptoms, not the ultimate diagnosis. The patient presented with severe chest pain and shortness of breath — symptoms a prudent layperson would identify as a medical emergency. The fact that the ultimate diagnosis was not a myocardial infarction does not invalidate the severity of the presentation. I am requesting this be routed for a clinical appeal."

The patient has hit the annual visit cap but still shows measurable functional improvement. The lever is an updated plan of care that reframes the visits as medically necessary to prevent deterioration — not purely rehabilitative — and demonstrates ongoing progress.

"I am requesting a medical necessity override for the physical therapy visit cap for member [Member ID]. The current therapy is not strictly rehabilitative but is medically necessary to prevent severe deterioration of the patient's condition. The treating therapist has submitted an updated plan of care detailing that the patient is still showing measurable functional improvement. I am requesting an exception to the policy cap based on active, ongoing clinical necessity."

A wheelchair or CPAP authorization has been stalled for weeks between the clinic, the insurer, and the DME vendor. Each points at the other. The lever is a live three-way conference — put the vendor on the line, call the insurer, and force the Certificate of Medical Necessity and face-to-face evaluation notes to move in real time.

"I am calling to execute a three-way conference to resolve the authorization for [Patient Name]'s [Equipment Type]. I have the DME vendor on the line. Insurer, can you confirm that you have received the Certificate of Medical Necessity and the face-to-face evaluation notes from the prescribing physician? If not, I have the clinic's records department ready to fax them directly to you while we hold. We need to clear this administrative hold today."

Calling a facility admissions director to vet clinical safety, not to tour. Surface-level amenities and daytime staffing are already on the brochure. The three data points that predict clinical safety are overnight ratios, agency reliance, and CMS survey deficiency history. Evasion on any of these is the red flag.

"I am evaluating your facility for my dependent and need specific clinical data, not general ranges. First, what is your exact, budgeted CNA-to-resident and RN-to-resident ratio on the overnight shift, between 11 PM and 7 AM? Second, what percentage of your nursing shifts in the last 30 days were filled by temporary agency staff rather than permanent employees? Finally, regarding your last CMS health inspection, can you detail the specific deficiencies cited and the exact operational changes you implemented to correct them?"