State Detail
Florida
12 plans reporting · CY 2025
Across 12 plans reporting in Florida, standard prior authorization denial rates range from 1.0% to 19.5%, averaging 8.3%. Among plans reporting appeal outcomes, 39.5% 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 |
| Centene Corporation | ||||||||||||||||||||||||||
| Wellcare Medicare Advantage (H1032)Medicare Advantage | Centene Corporation | 171,190 | 137,745 | 33,445 | 80.5% | 19.5% | 2,420 | 84.4% | 15.6% | 0.0% | 100.0% | 3.0 | 1.0 | 16,406 | 13,639 | 2,767 | 83.1% | 16.9% | 664 | 92.8% | 7.2% | 0.0% | 100.0% | 1.0 | 1.0 | View source ↗ |
| Sunshine Health Managed Medical Assistance (FL-MMA)Medicaid MCO | Centene Corporation | 418,298 | 341,693 | 76,605 | 81.7% | 18.3% | 7,401 | 49.4% | 50.6% | 1.6% | 98.5% | 2.0 | 1.0 | 13,003 | 11,238 | 1,765 | 86.4% | 13.6% | 2,478 | 86.5% | 13.5% | 3.0% | 97.0% | 1.0 | 0.0 | View source ↗ |
| Sunshine Health Title XXI CHIP (FL-CMS 21)CHIP | Centene Corporation | 37,267 | 33,028 | 4,239 | 88.6% | 11.4% | 702 | 27.4% | 72.7% | 0.9% | 99.1% | 2.0 | 0.0 | 810 | 785 | 25 | 96.9% | 3.1% | 110 | 91.8% | 8.2% | 1.7% | 98.3% | 1.0 | 0.0 | View source ↗ |
| Sunshine Health Title XIX Medicaid (FL-CMS 19)Medicaid MCO | Centene Corporation | 296,583 | 265,500 | 31,083 | 89.5% | 10.5% | 5,684 | 26.4% | 73.6% | 1.2% | 98.8% | 2.0 | 0.0 | 7,385 | 7,122 | 263 | 96.4% | 3.6% | 755 | 91.9% | 8.1% | 1.6% | 98.4% | 1.0 | 0.0 | View source ↗ |
| Sunshine Health Managed Long-Term Care (FL-LTC)Medicaid MCO | Centene Corporation | 135,110 | 133,255 | 1,855 | 98.6% | 1.4% | 2,093 | 22.0% | 78.0% | 0.8% | 99.2% | 2.0 | 0.0 | 411 | 378 | 33 | 92.0% | 8.0% | 8 | 62.5% | 37.5% | 11.4% | 88.6% | 2.0 | 1.0 | View source ↗ |
| Florida Blue / GuideWell | ||||||||||||||||||||||||||
| Florida Blue Medicare Advantage HMO (H1035)Medicare Advantage | Florida Blue / GuideWell | — | — | — | 91.0% | 9.0% | — | 55.0% | 45.0% | 0.0% | 0.0% | 2.1 | 0.0 | — | — | — | 92.0% | 8.0% | — | — | — | 0.0% | 0.0% | 0.6 | 0.2 | View source ↗ |
| Florida Blue Medicare Advantage PPO (H5434)Medicare Advantage | Florida Blue / GuideWell | — | — | — | 92.0% | 8.0% | — | 56.0% | 44.0% | 0.0% | 0.0% | 2.3 | 0.0 | — | — | — | 94.0% | 6.0% | — | — | — | 0.0% | 0.0% | 0.6 | 0.2 | View source ↗ |
| Florida Blue BlueOptions/BlueSelect QHP (16842)Exchange Plans | Florida Blue / GuideWell | — | — | — | 95.0% | 5.0% | — | 28.0% | 72.0% | 0.0% | 0.0% | 1.0 | 0.0 | — | — | — | 96.0% | 4.0% | — | — | — | 0.0% | 0.0% | 0.0 | 0.0 | View source ↗ |
| Florida Blue myBlue/BlueCare QHP (30252)Exchange Plans | Florida Blue / GuideWell | — | — | — | 99.0% | 1.0% | — | 30.0% | 70.0% | 0.0% | 0.0% | 0.2 | 0.0 | — | — | — | 98.0% | 2.0% | — | — | — | 0.0% | 0.0% | 0.0 | 0.0 | View source ↗ |
| Freedom Health | ||||||||||||||||||||||||||
| Freedom Health Medicare Advantage (FL HMO)Medicare Advantage | Freedom Health | — | — | — | 94.2% | 5.8% | — | 32.0% | 68.0% | — | — | 1.7 | 0.0 | — | — | — | 96.7% | 3.3% | — | — | — | — | — | — | — | View source ↗ |
| Humana Inc. | ||||||||||||||||||||||||||
| Humana Medicare Advantage (H1036)Medicare Advantage | Humana Inc. | 1,303,837 | 1,212,346 | 91,491 | 93.0% | 7.0% | 1,561 | 55.7% | 44.3% | 0.0% | 100.0% | 1.0 | 0.0 | 10,354 | 8,557 | 1,797 | 82.6% | 17.4% | — | — | — | 0.0% | 0.0% | — | — | View source ↗ |
| Humana Healthy Horizons Florida (Medicaid MCO)Medicaid MCO | Humana Inc. | 746,974 | 727,877 | 19,097 | 97.4% | 2.6% | 2,499 | 7.6% | 92.4% | 0.0% | 0.0% | 1.0 | 1.0 | 9,365 | 5,538 | 3,827 | 59.1% | 40.9% | — | — | — | 0.0% | 0.0% | — | — | 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