About This Project
Understanding the methodology and data behind the National Prior Authorization Tracker.
What is CMS-0057-F?
On January 17, 2024, the Centers for Medicare & Medicaid Services (CMS) finalized the Interoperability and Prior Authorization Final Rule (CMS-0057-F). This landmark regulation addresses long-standing concerns about delays and denials in the prior authorization process.
Starting March 31, 2026, impacted payers must publicly post aggregated prior authorization metrics from the prior calendar year. These metrics cover approval rates, denial rates, turnaround times, and appeal outcomes.
This is the first time this data has ever been publicly available.
Who Must Report?
The following payer types are required to report under CMS-0057-F:
- Medicare Advantage organizations
- Medicaid managed care plans (MCOs)
- CHIP managed care entities
- State Medicaid/CHIP fee-for-service programs
- Qualified Health Plan (QHP) issuers on Federally Facilitated Exchanges
Who Does NOT Report:
- Commercial fully-insured plans
- Self-funded employer plans
- Standalone Part D (drug-only) plans
What Metrics Are Required?
Payers must report the following prior authorization metrics for medical items and services:
- Approval and denial rates for standard requests
- Approval and denial rates for expedited requests
- Appeal outcomes (upheld vs. overturned)
- Extension outcomes
- Mean and median turnaround times for decisions
Only medical items and services are included. Drugs are excluded from the scope of CMS-0057-F prior authorization metrics.
About This Tool
There is no centralized federal database for prior authorization metrics. Each payer publishes its data independently, in widely varying formats — PDFs, HTML pages, Excel spreadsheets, and more.
This tool systematically collects, normalizes, and visualizes this data to make it accessible and comparable across payers. Every plan entry includes a link to the original source document.
Data Freshness & Caveats
- The first reporting deadline was March 31, 2026. Payers were required to post metrics covering calendar year 2025.
- Many payers may not have posted their data yet — coverage will grow over time as more organizations comply.
- Some reports may contain partial data where payers reported only a subset of the required metrics.
- Extraction confidence levels (high, partial, low) are noted per plan to indicate the reliability of the normalized data.
Resources
Methodology
This tracker compiles prior authorization metrics that regulated health plans must publish under CMS rule CMS-0057-F. Because CMS does not operate a central repository, each payer's data must be located and extracted individually.
Source discovery. Target payers are identified from CMS public use files: the Medicare Advantage Contract-Plan-State-County file, the Medicaid Managed Care Enrollment Report, and the FFE QHP landscape files. For each target, we search the payer's website, investor relations pages, regulatory compliance pages, and state insurance department filings for prior authorization metric disclosures.
Data extraction. Published reports appear in multiple formats — HTML tables, PDFs, and Excel files. Each source is downloaded and archived for auditability. Metrics are normalized to the 12 CMS-specified fields (approval rates, denial rates, appeal and overturn counts, and decision timeframes) for both standard and expedited request categories.
Normalization. National payers often report at the contract level rather than by state. Where this occurs, per-contract data is mapped to states using CMS service area files and averaged at the state level.
Validation. Every plan's data is checked for internal consistency: complementary rates must sum correctly, counts must align with reported percentages, and appeal overturn counts cannot exceed total appeals. Where a payer reports a percentage but omits the corresponding count (or vice versa), the missing value is derived. Each plan carries an extraction confidence rating — high, partial, or low — reflecting how cleanly the source data mapped to the required fields.
Update frequency. Source URLs are re-checked periodically to detect changes. The dataset is rebuilt after each update cycle.
Limitations
This dataset has known gaps and constraints that users should understand before drawing conclusions.
Incomplete coverage. Several of the largest national payers — including Anthem/Elevance Health, Kaiser Permanente, and Aetna — have not published compliant reports. The plans included here are not a representative sample of the U.S. insurance market.
Source fidelity. Some payers publish only percentages without underlying counts, or report at the contract level without clear state attribution. Where data is derived or averaged, the extraction confidence field reflects this.
No risk adjustment. Denial rates are not adjusted for case mix, clinical complexity, or service category. A plan with a high denial rate may serve a population with a different distribution of requested services than a plan with a low rate.
Point-in-time data. This reflects the first CY 2025 reporting cycle. Year-over-year trends will only become possible after the 2027 reporting deadline.
Frequently Asked Questions
What is prior authorization?
Prior authorization is a requirement imposed by health insurance plans that a proposed medical service, procedure, or prescription be approved before it is provided. The insurer reviews whether the requested care meets its coverage criteria. If the request is denied, the patient or provider must either appeal the decision, pursue an alternative treatment, or pay out of pocket. Under CMS-0057-F, regulated plans must now report how often they approve, deny, and overturn prior authorization requests.
What is CMS-0057-F?
CMS-0057-F is a federal rule finalized by the Centers for Medicare & Medicaid Services on January 17, 2024, titled the Interoperability and Prior Authorization Final Rule. It requires Medicare Advantage organizations, Medicaid managed care plans, CHIP managed care entities, state Medicaid/CHIP fee-for-service programs, and Qualified Health Plan issuers on federal exchanges to publish standardized prior authorization metrics annually. The first reports, covering calendar year 2025 data, were due March 31, 2026.
Which health insurance company denies the most prior authorizations?
Denial rates vary substantially across payers and plan types. Standard prior authorization denial rates range from under 2% to above 27% depending on the specific plan. Some of the highest denial rates appear among commercial QHP plans, while many Medicaid managed care plans report denial rates below 10%. Several major national payers — including Anthem/Elevance, Kaiser, and Aetna — have not yet published compliant data, so the current rankings are incomplete.
How often are prior authorization denials overturned on appeal?
Among plans reporting appeal outcomes, overturn rates on standard prior authorization appeals range from roughly 30% to above 75%. This means that at many plans, a majority of denials are reversed when challenged. However, not all denied requests are appealed — appeal filing rates are generally much lower than denial rates.
What is the average prior authorization denial rate?
There is no single national average because CMS does not aggregate the data centrally. Across the plans currently tracked, standard denial rates cluster between 4% and 15% for most Medicaid and Medicare Advantage plans. QHP (marketplace) plans show wider variation, with some reporting denial rates above 20%. These figures cover medical prior authorizations only — drug prior authorizations under Part D are excluded.
Which states have the highest prior authorization denial rates?
State-level denial rates depend on which plans operate in each state and which have reported. As more payers publish and coverage expands, state-level comparisons will become more robust.
Are health insurers required to publish prior authorization data?
Under CMS-0057-F, certain categories of health insurers must publish prior authorization metrics annually beginning in 2026. The requirement applies to Medicare Advantage organizations, Medicaid managed care organizations, CHIP managed care entities, state Medicaid and CHIP fee-for-service programs, and QHP issuers on federally facilitated exchanges. Commercial fully-insured plans, self-funded employer plans, and standalone Part D plans are not covered.
What is the difference between standard and expedited prior authorization?
Standard requests follow the plan's normal review timeline. Expedited requests are for situations where the standard timeline could seriously jeopardize the patient's life, health, or ability to regain maximum function; plans must process expedited requests within 72 hours. In the reported data, denial rates for expedited requests vary by plan.
How long does prior authorization take on average?
Average standard decision times range from under one day to over ten days depending on the plan. Expedited decisions are generally reported as under two days. These averages include approvals and denials combined and do not break out by service type.
What happens when a prior authorization is denied?
When a prior authorization is denied, the plan must notify the patient and provider. The patient or provider can then file an appeal. CMS-0057-F data shows that appeal overturn rates at many plans exceed 50%, meaning more than half of appealed denials are reversed. Beyond plan-level appeals, patients may have access to external review by an independent third party.