[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-287346-105":53,"doc-detail-287346-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","prior-authorization-appeal-request-form","Prior Authorization Appeal Request Form","","This document provides a formal Prior Authorization Appeal Request form designed for healthcare providers or members to challenge coverage decisions for prescription drugs. It outlines the mandatory submission timeline of 180 days from the original denial and distinguishes between standard (seven business days) and expedited (72 hours) review processing times. The form requires comprehensive patient and provider details, diagnosis information, and clear grounds for appeal, ensuring accurate documentation for reconsideration and clinical assessment.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/prior-authorization-appeal-request-form/287346/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/prior-authorization-appeal-request-form/287346.png","ImageObject",442,249,{"name":88,"@type":89},"Aria Callaghan","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-26","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What is the deadline for filing a prior authorization appeal?","Question",{"text":109,"@type":110},"An appeal must be initiated within 180 days of the original denial decision.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How long does the review process take for an appeal?",{"text":114,"@type":110},"Standard appeal requests are reviewed within seven business days, while expedited requests are reviewed within 72 hours if the member's health status is jeopardized.",{"name":116,"@type":107,"acceptedAnswer":117},"Where should the completed appeal form be submitted?",{"text":118,"@type":110},"The form and any supporting evidence should be faxed to 888-631-0862.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},287346,1790202619,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},962084926284,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","PRIOR AUTHORIZATION APPEAL REQUEST  \nAn appeal may be filed if you wish for us to reconsider and change a decision, we have made about what prescription drug benefits are covered for the member. The appeals process must be initiated within 180 days of the original denial. Standard appeal requests will be reviewed within seven business days. You may request an expedited appeal if the member’s health status is jeopardized by the standard processing time in which the appeal will be processed.  \nExpedited appeal requests will be reviewed within 72 hours. To make an appeal, please complete the form below and fax it to 888-631-0862, along with any additional supporting evidence. For questions regarding appeals, please contact provider services at 888-666-7271.  \nAPPEAL REQUEST  \nPlease indicate the request you are submitting:  \nSTANDARD – decision will be made within 7 working days  \nEXPEDITED – decision will be made within 72 hours  \nDate of Submission:    \n\n| PROVIDER INFORMATION |  | PATIENT INFORMATION |  |\n| --- | --- | --- | --- |\n| PROVIDER NAME | PROVIDER ID | PATIENT NAME |  |\n| PHYSICIAN ADDRESS (street, city, state, zip) |  | PATIENT’S MEMBER ID |  |\n| PHONE | FAX | PATIENT’S DOB | DIAGNOSIS |\n| If additional space is needed, please use separate sheet and attach to form. |  |  |  |\n| Prior Authorization Decision in Question: |  |  |  |\n| I do not agree with the determination of the Prior Authorization request. MY REASONS ARE: |  |  |  |\n| Additional information for us to consider: |  |  |  |\n|  |  |  |  |\n| I certify that the information above is accurate. I understand that penalties may apply for falsified or misrepresented information.\u003Cbr>Requester’s Signature:  Date: \u003Cbr>Requester’s Name:  Relationship to member: \u003Cbr>Requester’s Address  Requester’s phone:  |  |  |  |\n\nRxPreferred.com l (888) 666-7271 [l support@RxPreferred.com](l support@RxPreferred.com)","cbCaip7fSpllKWoD","https://ap.wps.com/l/cbCaip7fSpllKWoD","pdf",213773,"English","# Prior Authorization Appeal Process\n## Submission Guidelines\n## Required Information\n### Provider and Patient Details\n### Appeal Justification","[{\"question\":\"What is the deadline for filing a prior authorization appeal?\",\"answer\":\"An appeal must be initiated within 180 days of the original denial decision.\"},{\"question\":\"How long does the review process take for an appeal?\",\"answer\":\"Standard appeal requests are reviewed within seven business days, while expedited requests are reviewed within 72 hours if the member's health status is jeopardized.\"},{\"question\":\"Where should the completed appeal form be submitted?\",\"answer\":\"The form and any supporting evidence should be faxed to 888-631-0862.\"}]","Prior Authorization Appeal Request Form | PDF",1789632178]