State Detail
California
15 plans reporting · CY 2025
Across 15 plans reporting in California, standard prior authorization denial rates range from 1.0% to 12.0%, averaging 3.1%. Among plans reporting appeal outcomes, 61.6% of appealed denials are overturned. All data is from mandatory CMS-0057-F disclosures for calendar year 2025.
Plan Comparison
| Standard | Expedited | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Plan | Org | Requests | Approved | Denied | Appr % | Denial % ▼ | Appeals | Overturn % | Denied Appeal % | Appr Ext % | Denied Ext % | Mean Days | Med Days | Requests | Approved | Denied | Appr % | Denial % | Appeals | Overturn % | Denied Appeal % | Appr Ext % | Denied Ext % | Mean Days | Med Days | Source |
| Blue Shield of California | ||||||||||||||||||||||||||
| Blue Shield of California Medicare Advantage PPO (H4937)Medicare Advantage | Blue Shield of California | 3,829 | 3,368 | 461 | 88.0% | 12.0% | 145 | 74.0% | 26.0% | 67.0% | 33.0% | 4.0 | 3.0 | 559 | 546 | 13 | 98.0% | 2.0% | 114 | 67.0% | 33.0% | 64.0% | 36.0% | 1.0 | 0.8 | View source ↗ |
| Blue Shield of California Medicare Advantage HMO (H0504)Medicare Advantage | Blue Shield of California | 451,021 | 444,087 | 6,934 | 98.0% | 2.0% | 267 | 69.0% | 31.0% | 77.0% | 23.0% | 3.0 | 0.0 | 59,270 | 57,828 | 1,442 | 98.0% | 2.0% | 125 | 73.0% | 27.0% | 76.0% | 24.0% | 0.6 | 0.3 | View source ↗ |
| Blue Shield of California Medicare Advantage HMO (H5928)Medicare Advantage | Blue Shield of California | 67,137 | 66,127 | 1,010 | 98.0% | 2.0% | 28 | 71.0% | 29.0% | 86.0% | 14.0% | 2.0 | 0.0 | 7,251 | 7,099 | 152 | 98.0% | 2.0% | 7 | 86.0% | 14.0% | 0.0% | 100.0% | 0.4 | 0.2 | View source ↗ |
| Blue Shield of California Medicare Advantage DSNP (H2819)Medicare Advantage | Blue Shield of California | 122,926 | 121,309 | 1,617 | 99.0% | 1.0% | 74 | 81.0% | 19.0% | 59.0% | 41.0% | 3.0 | 0.0 | 13,775 | 13,392 | 383 | 97.0% | 3.0% | 36 | 75.0% | 25.0% | 33.0% | 67.0% | 0.5 | 0.3 | View source ↗ |
| Cedars-Sinai | ||||||||||||||||||||||||||
| Cedars-Sinai Health PlanMedicare Advantage | Cedars-Sinai | 69,897 | 68,670 | 1,227 | 98.2% | 1.8% | 10 | 40.0% | 60.0% | — | — | 3.5 | 0.0 | 9,679 | 9,480 | 199 | 97.9% | 2.1% | 60 | 76.7% | 23.3% | — | — | 0.8 | 0.0 | View source ↗ |
| Centene Corporation | ||||||||||||||||||||||||||
| Community Health Plan of Imperial Valley Medi-CalMedicaid MCO | Centene Corporation | 57,406 | 53,059 | 4,347 | 92.4% | 7.6% | 77 | 48.0% | 52.0% | 0.3% | 99.7% | 3.0 | 1.0 | 13,973 | 13,529 | 444 | 96.8% | 3.2% | 16 | 37.5% | 62.5% | 0.1% | 99.9% | 1.0 | 1.0 | View source ↗ |
| CalViva Health Medi-CalMedicaid MCO | Centene Corporation | 310,319 | 290,654 | 19,665 | 93.7% | 6.3% | 493 | 48.3% | 51.7% | 0.3% | 99.7% | 3.0 | 0.0 | 42,465 | 40,299 | 2,166 | 94.9% | 5.1% | 76 | 47.4% | 52.6% | 0.2% | 99.8% | 1.0 | 0.0 | View source ↗ |
| Health Net Medi-CalMedicaid MCO | Centene Corporation | 3,096,168 | 3,020,354 | 75,814 | 97.5% | 2.5% | 1,017 | 39.7% | 60.3% | 0.3% | 99.7% | 2.0 | 0.0 | 394,719 | 377,670 | 17,049 | 95.7% | 4.3% | 191 | 37.7% | 62.3% | 0.2% | 99.8% | 1.0 | 0.0 | View source ↗ |
| Wellcare By Health Net Medicare Advantage (H3561)Medicare Advantage | Centene Corporation | 290,257 | 284,520 | 5,737 | 98.0% | 2.0% | 120 | 77.5% | 22.5% | 63.6% | 36.4% | 3.0 | 1.0 | 40,022 | 38,810 | 1,212 | 97.0% | 3.0% | 32 | 81.3% | 18.8% | 62.5% | 37.5% | 0.0 | 1.0 | View source ↗ |
| Wellcare By Health Net Medicare Advantage (H0562)Medicare Advantage | Centene Corporation | 184,541 | 180,957 | 3,584 | 98.1% | 1.9% | 92 | 77.2% | 22.8% | 57.1% | 42.9% | 3.0 | 1.0 | 24,953 | 24,237 | 716 | 97.1% | 2.9% | 23 | 95.7% | 4.3% | 100.0% | 0.0% | 1.0 | 1.0 | View source ↗ |
| Inland Empire Health Plan | ||||||||||||||||||||||||||
| IEHP CoveredExchange Plans | Inland Empire Health Plan | 92,672 | 90,811 | 1,861 | 98.0% | 2.0% | — | 100.0% | 0.0% | — | — | 5.2 | 6.1 | 24,380 | 23,825 | 555 | 98.0% | 2.0% | — | — | — | — | — | 0.4 | 0.1 | View source ↗ |
| IEHP DualChoice (HMO D-SNP)Medicare Advantage | Inland Empire Health Plan | 378,624 | 370,653 | 7,971 | 98.0% | 2.0% | — | 100.0% | 0.0% | — | — | 2.6 | 1.0 | 82,531 | 80,368 | 2,163 | 97.0% | 3.0% | — | — | — | — | — | 0.6 | 0.0 | View source ↗ |
| IEHP Medi-CalMedicaid MCO | Inland Empire Health Plan | 3,017,509 | 2,984,867 | 32,642 | 99.0% | 1.0% | — | 99.0% | 1.0% | — | — | 2.1 | 0.6 | 543,529 | 537,136 | 6,393 | 99.0% | 1.0% | — | — | — | — | — | 0.2 | 0.0 | View source ↗ |
| L.A. Care Health Plan | ||||||||||||||||||||||||||
| L.A. Care Health Plan Medi-CalMedicaid MCO | L.A. Care Health Plan | 2,152,883 | 2,112,850 | 40,033 | 98.1% | 1.9% | — | 0.0% | 100.0% | 0.4% | 99.6% | 4.6 | 3.0 | 350,767 | 337,522 | 13,245 | 96.2% | 3.8% | — | — | — | 0.8% | 99.2% | 1.0 | 0.0 | View source ↗ |
| L.A. Care Medicare Plus (HMO D-SNP)Medicare Advantage | L.A. Care Health Plan | 284,406 | 281,471 | 2,935 | 99.0% | 1.0% | — | 0.0% | 100.0% | 0.0% | 100.0% | 5.5 | 4.0 | 31,016 | 30,377 | 639 | 97.9% | 2.1% | — | — | — | 0.0% | 100.0% | 2.0 | 1.2 | View source ↗ |
Standard Denial Rates by Plan
Appeals Analysis
Plans in the upper-right deny frequently and have high overturn rates — suggesting inappropriate denials.
Similar Denial Rates