Read this page before using PriorAuthPro. It explains in plain language what this tool does, what it does not do, and what you are responsible for before filing an appeal.
PriorAuthPro is not a law firm and does not provide legal or medical advice.
1. What PriorAuthPro Is and Is Not
PriorAuthPro is a documentation tool. It takes information you enter about your denial, looks up the submission rules for your insurer, and generates a structured set of documents you can use to file a prior authorization appeal. That is the complete scope of what it does.
| PriorAuthPro does this | PriorAuthPro does not do this |
|---|---|
| Generates structured appeal documents based on your input | Evaluate whether your denial was correct |
| Provides insurer-specific submission instructions | Submit your appeal for you |
| Calculates your filing deadline from the denial date | Contact your insurer on your behalf |
| Generates a Letter of Medical Necessity template for your provider to complete | Provide medical or clinical advice |
| Provides state-specific escalation pathway information | Provide legal advice or representation |
| Organizes your appeal materials into a single downloadable packet | Guarantee that your appeal will be approved |
The current version of PriorAuthPro covers the following only. If your situation falls outside this scope, the documents generated may not reflect your insurer's actual requirements.
- Supported insurers: UnitedHealthcare, Aetna, and Blue Cross Blue Shield (major commercial plans only)
- Supported denial type: Medical necessity denials
- Supported plan types: Commercial HMO, Commercial PPO, and Marketplace (ACA) plans
- Supported appeal level: Level 1 (Initial Appeal) only
If your insurer, plan type, or denial reason is not listed above, PriorAuthPro is not the right tool for your situation at this time.
2. No Legal Advice
PriorAuthPro is not a law firm. PatientLead Health LLC does not employ licensed attorneys in connection with this service. Nothing you receive from PriorAuthPro is legal advice.
Using PriorAuthPro does not create an attorney-client relationship between you and PatientLead Health LLC or anyone associated with the company. You are not represented by an attorney. You have not received a legal opinion. The documents generated by PriorAuthPro are not a substitute for legal counsel.
Prior authorization appeals are administrative proceedings with real legal dimensions. Your rights are governed by federal law (including ERISA and the Affordable Care Act), state law, and your specific plan documents. PriorAuthPro organizes information into a structured format. It does not interpret your legal rights, advise you on legal strategy, or apply legal principles to your specific circumstances.
If any of the following apply to your situation, you should speak with a licensed attorney before proceeding:
- Your plan is a self-funded employer plan (ERISA governs these plans, not state insurance law)
- Your internal appeal has already been denied and you are considering external review or litigation
- Your denial involves a large dollar amount or ongoing treatment with significant health consequences
- Your insurer is claiming a plan exclusion rather than a medical necessity determination
- You have received legal correspondence from your insurer or its counsel
3. No Medical Advice
PriorAuthPro is not a medical service. It does not evaluate your treatment plan, assess whether your treatment meets your insurer's clinical criteria, or determine whether your diagnosis justifies the requested treatment. These are clinical judgments that belong to licensed medical professionals.
The documents PriorAuthPro generates reflect the information you enter. The tool does not check, verify, or correct your medical information. If you enter an inaccurate diagnosis description or incomplete treatment history, those inaccuracies will appear in your documents.
When entering your diagnosis, use the exact language from your medical records or denial letter. Do not paraphrase. If your records say "lumbar disc herniation with radiculopathy," enter that phrase, not "back pain." The documents generated will reflect what you enter.
PriorAuthPro does not assess whether your appeal will succeed on clinical grounds. That determination is made by your insurer's clinical reviewers and, if appealed externally, by an independent review organization. Generating a packet does not mean your clinical documentation is sufficient.
4. No Guarantee of Outcome
PriorAuthPro makes no promise that your appeal will be approved. It does not promise that your packet will satisfy your insurer's specific requirements. It does not promise that you will meet your filing deadline. Appeal outcomes are determined solely by your insurer based on your insurer's clinical criteria, plan terms, and internal review processes.
The phrases "complete packet" and "ready to submit" describe the structure of the documents, not a guarantee that every submission requirement for your specific plan has been met. You remain responsible for verifying that your packet is complete before filing.
5. Insurer Data Accuracy and Verification
The submission rules, deadlines, portal URLs, and fax numbers in PriorAuthPro come from publicly available insurer policy documents and insurer websites. This information is not provided directly by insurers and is not verified by insurers. Insurer requirements change without notice.
PriorAuthPro verifies insurer data on a quarterly basis. Every packet you generate displays the date this data was last verified. Quarterly verification does not mean the information is current on the day you generate your packet. Between verification cycles, portal URLs may change, fax numbers may be retired, submission requirements may be updated, and deadlines may be modified by plan amendments or regulatory changes.
Before you submit your appeal, independently confirm the correct submission channel (portal, fax, or mail), the correct portal URL or fax number, your actual filing deadline as stated on your denial letter, and any format requirements your insurer has posted since the last verification date. Do not rely solely on the information in your packet for these details.
If the insurer data used to generate your packet is more than 90 days old at the time of generation, the service will display a data-age warning. If you see this warning, treat the submission details in your packet as a starting point for verification, not as confirmed current information.
6. Blue Cross Blue Shield Notice
Blue Cross Blue Shield is not a single national insurer. It is a federation of independent, locally operated affiliate plans. There is no single national BCBS portal, mailing address, fax number, or appeals phone number.
PriorAuthPro cannot pre-populate your BCBS submission details the way it can for UnitedHealthcare or Aetna. The submission channel, portal URL, fax number, and mailing address for a BCBS appeal depend entirely on which local BCBS affiliate administers your plan.
How to identify your affiliate: Look at the three-letter prefix on your member ID card. That prefix identifies your local Blue plan. All submission details must come from your denial letter or from the member services number on the back of your card.
The BCBS packet generated by PriorAuthPro provides the cover letter, evidence checklist, care timeline, Letter of Medical Necessity template, deadline worksheet, and escalation overview. It instructs you to obtain submission details from your denial letter. If you need a portal URL, fax number, or mailing address pre-filled for a BCBS plan, this tool cannot provide that information with confidence.
If this limitation affects whether the tool is right for you, please review this notice before purchasing.
7. Your Denial Letter Is the Source of Truth
The information in your denial letter or Explanation of Benefits (EOB) controls. Wherever the information in your PriorAuthPro packet conflicts with what is printed on your denial letter, your denial letter is correct and your packet is not.
If your denial letter lists a specific fax number, mailing address, or portal URL for appeals, use that address. Do not substitute the general insurer contact information from your packet for contact information printed directly on your denial letter. Insurers sometimes route appeals through specific regional departments, and mailing to a general address can delay or prevent review.
Your denial letter also controls your filing deadline. The deadline shown in your PriorAuthPro deadline worksheet is calculated from the denial date you entered and the general appeal window for your insurer and plan type. Verify the actual deadline stated on your denial letter before relying on the calculated date.
8. Letter of Medical Necessity Template
The Letter of Medical Necessity (LMN) included in your packet is a structured template. It is not a completed document. It cannot be submitted to your insurer as-is.
The LMN template contains placeholders that your treating provider must fill in. These include the ICD-10 diagnosis code, clinical findings, treatment rationale, prior therapy failure documentation, and the provider's signature and NPI number. Generating a packet does not complete the LMN. You are responsible for engaging your provider, sharing the template, and obtaining a completed and signed LMN before submitting your appeal.
PriorAuthPro does not contact providers on your behalf. It does not verify that your provider will complete the template. It does not assess whether the clinical content your provider enters will satisfy your insurer's medical necessity criteria. The clinical content of the LMN is your provider's responsibility.
9. State-Specific Notices
Several states maintain laws that are directly relevant to the scope of this service. Users in the following states should read the applicable notice before using PriorAuthPro.
California has a broad unauthorized practice of law statute that has been applied to document preparation services in administrative proceedings. By using PriorAuthPro, you acknowledge that no attorney-client relationship exists, that you have not received legal advice, and that PriorAuthPro has not represented you in any proceeding.
California also requires that businesses providing document preparation services be registered as Legal Document Assistants (LDAs) in some circumstances. PatientLead Health LLC is evaluating LDA registration. For complex appeals involving significant benefit amounts or ERISA plan disputes, California users are encouraged to consult a licensed attorney or a state-registered patient advocate.
New York's unauthorized practice of law statute applies broadly to services that apply legal principles to specific facts in administrative proceedings. By using PriorAuthPro, you acknowledge that no attorney-client relationship exists and that you have not received legal advice. For appeals involving denied cancer treatment, mental health services, or experimental treatments, New York users may have specific additional rights under state law that this tool does not address. Consult the New York Department of Financial Services or a licensed attorney for guidance.
Texas has both an unauthorized practice of law statute and a separate Insurance Code framework governing health plan appeals. By using PriorAuthPro, you acknowledge that no attorney-client relationship exists and that you have not received legal advice. Texas users whose appeals involve Independent Review Organization (IRO) processes should verify current IRO filing procedures directly with the Texas Department of Insurance, as these procedures may differ from the general escalation information in your packet.
Florida's unauthorized practice of law statute has been applied in contexts involving document preparation for administrative proceedings. By using PriorAuthPro, you acknowledge that no attorney-client relationship exists and that you have not received legal advice. Florida users should note that self-funded ERISA plans are not regulated by the Florida Office of Insurance Regulation, and the escalation information in your packet may not apply to your plan. Verify your plan type with your employer's HR department if you are unsure.
Illinois has a broad unauthorized practice of law statute. By using PriorAuthPro, you acknowledge that no attorney-client relationship exists and that you have not received legal advice. Illinois users with Medicaid managed care plan denials should note that PriorAuthPro does not cover Medicaid plans at this time and that a separate appeals process applies under Illinois Medicaid regulations.
Regardless of your state, no attorney-client relationship is formed by using PriorAuthPro. PatientLead Health LLC is not a law firm, does not provide legal advice, and has not represented you in any proceeding. If your state is not listed above, the general disclaimers on this page and in the Terms of Service apply in full.
10. Limitation of Liability
The full limitation of liability governing your use of PriorAuthPro is set out in Section 11 of the Terms of Service. The following is a plain-language summary, not a replacement for those terms.
In plain terms: if something goes wrong with your appeal, the most the company can owe you under these terms is the $59 you paid for the packet. The company is not liable for the cost of denied medical care, for missing a deadline, or for an appeal that is rejected for any reason.
Some states do not allow these limitations for consumer transactions. In those states, the limitations above apply only to the maximum extent permitted by applicable law.
11. When You Need More Help Than This Tool Provides
PriorAuthPro is built for a specific situation: a patient with a medical necessity denial from one of three major insurers who needs structured documentation to file a Level 1 initial appeal. If your situation is more complex, more urgent, or falls outside that scope, here are the resources most likely to help.
- Your state's Department of Insurance Can explain your rights, file a complaint, and in many states initiate an external review on your behalf. Search "[your state] Department of Insurance" to find the correct agency.
- Patient advocate services Independent patient advocates specialize in insurance disputes and can often represent you directly. The Patient Advocate Foundation (patientadvocate.org) offers case management services and can connect you with advocates for specific conditions.
- Legal aid organizations If cost is a barrier to legal help, your state's legal aid society may be able to assist with insurance appeals, particularly for denials involving ongoing or life-sustaining treatment. Search "[your state] legal aid health insurance" to find local resources.
- CMS.gov For Medicare and marketplace plan questions, the Centers for Medicare and Medicaid Services publishes guidance on appeal rights and processes at cms.gov.
- Your insurer's member services line The phone number on the back of your member ID card. Ask specifically for the appeals department and request a written explanation of the clinical criteria used to deny your claim.
- Your treating provider's office Your provider and their billing staff often have experience with specific insurers and can advise on what documentation typically supports a successful appeal for your condition and treatment type.
If your health is at urgent risk and you cannot wait for a standard appeal timeline, most insurers are required to provide an expedited review process. Contact your insurer's appeals department directly to request an expedited review and ask for the timeline. Your denial letter should specify whether an expedited review option is available for your denial type.