Appeal a prior authorization denial
Paste the denial and clinical notes — River drafts a complete appeal letter that addresses the payer's criteria directly.
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River's Prior Authorization Appeal Generator drafts complete prior authorization appeal letters that address the payer's denial criteria directly — with clinical justification, step therapy documentation tables, guideline citations, and a structured appeal letter ready for submission. Select the denial reason, what was denied, and what supporting facts apply, and the AI generates a focused appeal.
Prior authorization denials are overturned at higher rates when appeals directly address the payer's specific coverage criteria rather than making generic medical necessity arguments. This tool helps you write the kind of focused, evidence-based appeal that peer reviewers actually read — not a generic template.
Use this for first-level appeals, second-level appeals, peer-to-peer review requests, and external independent review submissions. Works for medications, imaging, procedures, therapy, DME, and inpatient/observation stay denials.
Writing Prior Auth Appeals That Work
The single most effective thing you can do in a PA appeal is address the payer's specific coverage criteria by name. Find the payer's clinical policy document — it's usually available on their website under 'clinical policies' or 'medical policies' — and structure your appeal around it. If the policy requires two prior medication failures, document exactly two: drug name, dose, duration, outcome, and why it was stopped.
Step therapy appeals require precise documentation. Vague statements like 'the patient tried other medications' are consistently denied. Document each prior treatment as a table: medication name, dose, start and end date, clinical outcome (inadequate response, adverse effect, contraindication), and the specific reason it was discontinued. This structured format is easier for the reviewer to verify and harder to deny.
For peer-to-peer reviews, request physician-to-physician contact within the appeal letter itself. Include your direct phone number and available times. A peer-to-peer review converts many denials to approvals because the reviewer can ask specific questions and you can provide clinical context that isn't in the written record. Frame it as a collegial clinical discussion, not a confrontation.
What You Get
Complete appeal letter addressing the payer's denial criteria
Step therapy documentation table (when applicable)
Clinical guideline citations supporting necessity
Peer-to-peer review request language
Supporting documentation checklist
Plain-text format ready to paste into payer portals or submit by fax
How It Works
- 1Paste the denial and clinical notesInclude the PA denial letter and any clinical documentation supporting the request
- 2Select denial type and supporting factsChoose why it was denied and what clinical evidence applies
- 3AI drafts the appealRiver generates a complete appeal letter addressing the specific denial criteria
- 4Review, sign, and submitReview the letter, add any missing details, and submit by the appeal deadline
Frequently Asked Questions
How quickly do I need to file a PA appeal?
Most payers require first-level appeals within 60-180 days of the denial date. Second-level appeals typically must be filed within 60 days of the first-level denial. For Medicare Advantage plans, check the plan's Evidence of Coverage. Missing the deadline eliminates your right to appeal, so file quickly even with an incomplete appeal — you can supplement with additional documentation during the review period.
Should I request a peer-to-peer review or file a written appeal?
Both, when possible. File the written appeal to preserve your rights and meet the deadline, and simultaneously request a peer-to-peer review. Peer-to-peer reviews are especially effective for specialty medication denials and high-cost procedures, where a physician reviewer can ask specific clinical questions and you can provide context that isn't in the written record. Some payers have short windows for peer-to-peer requests (48-72 hours), so request it immediately after the denial.
Can I paste the payer's clinical policy to improve the output?
Yes — this is the single most effective thing you can add. Find the payer's clinical policy or coverage determination for the requested service on their website. Paste it along with the clinical notes. The AI will use the policy criteria as the explicit framework and address each criterion in the appeal, dramatically improving the specificity and effectiveness of the letter.
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