Organization Detail
CalOptima Health
2 plans across 1 state · Medicaid MCOMedicare Advantage
CalOptima Health reported prior authorization metrics for 2 Medicaid MCO, Medicare Advantage plans across 1 state under CMS rule CMS-0057-F for calendar year 2025. Across those plans, CalOptima Health processed 1,060,023 standard prior authorization requests. The average standard prior authorization denial rate was 1.5%, below the national average of 11.8%. When patients or providers appealed denied prior authorizations, 29.4% of appeals were overturned on average. Standard prior authorization decisions took an average of 1.6 days.
1.5%
CalOptima Health Denial Rate
standard, avg across 2 plans
11.8%
National Average
all reporting plans
-10.3%
vs. National
below average
CA2 plans
| Plan | Requests | Approved | Denied | Appr % | Denial % ▼ | Appeals | Overturn % | Denied Appeal % | Appr Ext % | Denied Ext % | Mean Days | Med Days |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CalOptima Health Medi-CalMedicaid MCO | 965,191 | 948,623 | 16,568 | 98.3% | 1.7% | 1,080 | 28.3% | 71.7% | 0.2% | 0.1% | 1.4 | 0.0 |
| CalOptima Health OneCare (HMO D-SNP)Medicare Advantage | 94,832 | 93,521 | 1,311 | 98.6% | 1.4% | 108 | 30.6% | 69.4% | 0.2% | 0.0% | 1.8 | 0.0 |