Niti Logic Â· Free Worksheet

Denial Response Planner

Use one planner per denial â€” complete as soon as you receive a denial notice. The information you record here will guide every subsequent step.

Worksheet Â· Print Friendly

Denial Navigation

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Denial Details

Patient Name

Date of Denial Notice

Insurance Plan

Claim / Reference Number

What Was Denied (Medication / Test / Procedure)

Appeal Deadline

Reason Given for Denial â€” Copy the exact wording from the denial notice

Primary Diagnosis Code (ICD) Submitted

Other Diagnoses or Comorbidities That Apply

Ask your provider's office which diagnosis codes were submitted. If relevant conditions were omitted, notify the office immediately â€” this is one of the fastest fixes for a denial.

Step Therapy / Prior Treatments â€” Critical

List all treatments, medications, or therapies already tried for this condition. Include history from any provider at any time, even years ago.

Treatment / Medication	Approx. Dates	Dose	Outcome / Side Effects	Provider / Facility

Action Plan

Provider actions needed:

Submit additional documentation

Request peer-to-peer review

Submit formal appeal letter

Submit new prior authorization

Provide updated medical records

Patient actions needed:

Request copy of denial letter

Obtain medical records from outside providers

Gather pharmacy history printout

Confirm appeal submission with office

Monitor for insurer response

Documents to Gather

Denial letter (original)

Relevant medical records

Lab results / imaging reports

Medication / pharmacy history

Previous treatments documentation

Specialist notes

Status Tracking

Status	Date	Notes

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