State Detail
Massachusetts
9 plans reporting · CY 2025
Across 9 plans reporting in Massachusetts, standard prior authorization denial rates range from 4.0% to 14.6%, averaging 8.9%. Among plans reporting appeal outcomes, 46.6% 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 |
| Commonwealth of Massachusetts | ||||||||||||||||||||||||||
| MassHealth (Fee-for-Service)Medicaid FFS | Commonwealth of Massachusetts | — | — | — | 85.4% | 14.6% | — | 29.5% | 70.5% | 78.8% | 21.2% | 4.2 | 2.0 | — | — | — | 78.2% | 21.8% | — | — | — | — | — | 1.3 | 0.1 | View source ↗ |
| MassHealth / EOHHS | ||||||||||||||||||||||||||
| MassHealth (Massachusetts Medicaid FFS)Medicaid FFS | MassHealth / EOHHS | — | — | — | 85.4% | 14.6% | — | 29.5% | 70.5% | 78.8% | 21.2% | 4.2 | 2.0 | — | — | — | 78.2% | 21.8% | — | — | — | — | — | 1.3 | 0.1 | View source ↗ |
| Molina Healthcare | ||||||||||||||||||||||||||
| Senior Whole Health SCOMedicaid MCO | Molina Healthcare | — | — | — | 92.0% | 8.0% | — | 61.0% | 39.0% | — | — | 2.0 | 1.0 | — | — | — | 93.0% | 7.0% | — | — | — | — | — | 0.9 | 0.7 | View source ↗ |
| Point32Health | ||||||||||||||||||||||||||
| Tufts Health Together MCO (Point32Health)Medicaid MCO | Point32Health | 2,058 | 1,906 | 152 | 92.6% | 7.4% | — | — | — | — | — | 4.9 | 3.9 | 229 | 195 | 34 | 85.2% | 14.8% | — | — | — | — | — | 0.6 | 0.2 | View source ↗ |
| Tufts Health Together with UMass Memorial Health (Point32Health)Medicaid MCO | Point32Health | 6,367 | 6,036 | 331 | 94.8% | 5.2% | — | — | — | — | — | 4.6 | 4.9 | 512 | 441 | 71 | 86.1% | 13.9% | — | — | — | — | — | 1.3 | 0.8 | View source ↗ |
| Tufts Health Plan One Care - Medicare-Medicaid (Point32Health)Medicaid MCO | Point32Health | 9,942 | 9,497 | 445 | 95.5% | 4.5% | — | — | — | — | — | 4.0 | 2.7 | 686 | 612 | 74 | 89.2% | 10.8% | — | — | — | — | — | 0.3 | 0.1 | View source ↗ |
| Tufts Health Together with Cambridge Health Alliance (Point32Health)Medicaid MCO | Point32Health | 3,526 | 3,386 | 140 | 96.0% | 4.0% | — | — | — | — | — | 5.2 | 3.9 | 152 | 132 | 20 | 86.8% | 13.2% | — | — | — | — | — | 2.1 | 0.2 | View source ↗ |
| WellSense Health Plan (formerly BMC HealthNet Plan) | ||||||||||||||||||||||||||
| WellSense Health Plan - Massachusetts ClarityExchange Plans | WellSense Health Plan (formerly BMC HealthNet Plan) | 49,926 | 43,880 | 6,046 | 88.0% | 12.0% | 48 | 58.0% | 42.0% | — | — | 1.3 | 0.1 | 2,113 | 1,916 | 197 | 91.0% | 9.0% | 6 | 33.0% | 67.0% | — | — | 0.5 | 0.1 | View source ↗ |
| WellSense Health Plan - MassHealth MedicaidMedicaid MCO | WellSense Health Plan (formerly BMC HealthNet Plan) | 214,504 | 192,638 | 21,866 | 90.0% | 10.0% | 271 | 55.0% | 45.0% | — | — | 4.0 | 1.0 | 8,735 | 8,194 | 541 | 94.0% | 6.0% | 3 | 67.0% | 33.0% | — | — | 0.4 | 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