Healthcare Prior Authorization
Upload prior auth requests, clinical notes, and payer requirements. SaralFlow builds a complete packet with missing clinical evidence flagged before submission.
Sample packet
Prior-auth packet
Sample request · Demo patient case (fictional)
Executive summary
What happened, what matters, and what to do next — from documents SaralFlow reviewed.
Prior authorization request for MRI lumbar spine (CPT 72148) — diagnosis M54.5 low back pain.
Conservative care documented: 6 weeks physical therapy and 8 weeks NSAIDs before imaging request.
Blue Shield PPO requires prior auth; deductible met — estimated patient copay $150.
2024 lumbar X-ray supports medical necessity but is not referenced in the necessity letter — denial risk.
MRI scheduled May 6 — payer submission deadline April 30 (5 business days before appointment).
Key findings
- Patient/request: MRI lumbar spine (CPT 72148) for M54.5 low back pain — Dr. A. Ramirez
- Diagnosis and treatment evidence: 6 weeks PT + 8 weeks NSAIDs documented in clinical notes
- Payer requirement checklist: conservative care ✓, necessity letter ✓, referral ✓, imaging link ⚠
- 2024 lumbar X-ray shows degenerative changes — supports request but not cited in necessity letter
- Missing clinical support: prior imaging cross-reference needed in medical necessity letter
- Coverage: Blue Shield PPO · deductible met · patient copay $150
- Submission-ready packet 90% complete — deadline April 30 before May 6 MRI
Timeline
- 2026-01-10 — Conservative care start
PT and NSAID protocol initiated
- 2026-03-15 — Specialist referral
PCP referral to Dr. A. Ramirez — orthopedic spine
- 2026-04-25 — Auth packet assembled
Clinical notes, necessity letter, and policy summary reviewed
- 2026-04-30 — Submission deadline
Must submit to payer before May 6 MRI appointment
Output sections
Authorization request
- Procedure: MRI Lumbar Spine (CPT 72148)
- Diagnosis: Low back pain (ICD-10 M54.5)
- Provider: Dr. A. Ramirez, MD
- Facility: Southwest Spine Center
Criteria checklist
- Conservative care documented ✓
- Medical necessity letter signed ✓
- Referral current and valid ✓
- Prior imaging needs linking — ⚠
Coverage & cost
- Plan: Blue Shield PPO
- Prior auth required: Yes
- Deductible: Met ✓
- Patient copay: $150
Submission packet
- Auth request form ready
- Clinical notes (3 visits) included
- Necessity letter — update imaging reference
- Deadline: April 30
Source evidence
- Prior authorization request form Confirmed
- Clinical notes — Dr. Ramirez (3 visits) Confirmed
- Medical necessity letter Confirmed
- Insurance policy — coverage summary Confirmed
- Referral from PCP Confirmed
- Previous imaging report (2024) Needs review
Documents reviewed
Prior authorization request form
ConfirmedAuth Request
Procedure: MRI lumbar spine · ICD-10: M54.5 · CPT: 72148
Clinical notes — Dr. Ramirez (3 visits)
ConfirmedClinical Notes
Conservative treatment history documented: PT × 6 weeks, NSAIDs × 8 weeks
Medical necessity letter
ConfirmedNecessity Letter
Signed by Dr. Ramirez · 3-month conservative care history included
Insurance policy — coverage summary
ConfirmedPolicy Document
MRI covered with prior auth · $500 deductible met · $150 copay
Referral from PCP
ConfirmedReferral
Referral to orthopedic specialist — current and valid
Previous imaging report (2024)
Needs reviewImaging Report
2024 X-ray shows degenerative changes — supports necessity but needs linking
Issues needing review
→ Prior imaging not referenced in necessity letter — 2024 X-ray shows degenerative changes. Reference it explicitly in the medical necessity letter to strengthen the case.
→ Submission deadline: 5 business days — MRI scheduled May 6. Prior auth must be submitted by April 30 to avoid denial.
→ Conservative care well-documented — 6 weeks PT + 8 weeks NSAIDs documented — meets most payer criteria for imaging.
Missing documents
- Prior imaging needs linking — ⚠
- Prior imaging cross-reference in medical necessity letter — payer may deny without explicit link to 2024 X-ray findings
- Updated necessity letter signature date — ensure letter reflects current imaging reference before fax/portal upload
Recommended next actions
Auth request form ready
Auth request form ready
Clinical notes (3 visits) included
Clinical notes (3 visits) included
Necessity letter
Necessity letter — update imaging reference
Deadline: April 30
Deadline: April 30
Sample · Demo data — fictional patient case. Not medical or legal advice.