State Detail
New York
33 plans reporting · CY 2025
Across 33 plans reporting in New York, standard prior authorization denial rates range from 3.2% to 42.2%, averaging 16.8%. Among plans reporting appeal outcomes, 42.9% 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 | ||||||||||||||||||||||||||
| Fidelis Care MLTCMedicaid MCO | Centene Corporation | 44,469 | 32,261 | 12,208 | 72.5% | 27.5% | 1,213 | 28.9% | 71.2% | — | — | 4.0 | — | 517 | 362 | 155 | 70.0% | 30.0% | 74 | 27.0% | 73.0% | — | — | 5.0 | — | View source ↗ |
| Fidelis Care MedicaidMedicaid MCO | Centene Corporation | 1,060,258 | 777,648 | 282,610 | 73.4% | 26.6% | 10,242 | 28.8% | 71.2% | — | — | 3.0 | — | 30,954 | 23,399 | 7,555 | 75.6% | 24.4% | 1,237 | 54.4% | 45.6% | — | — | 2.0 | — | View source ↗ |
| Fidelis Care Child Health PlusCHIP | Centene Corporation | 46,752 | 34,752 | 12,000 | 74.3% | 25.6% | 391 | 32.2% | 67.8% | — | — | 2.0 | — | 1,359 | 1,052 | 307 | 77.4% | 22.6% | 49 | 53.1% | 46.9% | — | — | 1.0 | — | View source ↗ |
| Fidelis Care Essential PlanMedicaid MCO | Centene Corporation | 286,283 | 225,033 | 61,250 | 78.6% | 21.4% | 1,906 | 26.2% | 73.8% | — | — | 3.0 | — | 7,122 | 5,276 | 1,846 | 74.1% | 25.9% | 251 | 49.0% | 51.0% | — | — | 3.0 | — | View source ↗ |
| Wellcare by Fidelis Medicare (H5599)Medicare Advantage | Centene Corporation | 154,811 | 127,418 | 27,393 | 82.3% | 17.7% | 2,176 | 98.1% | 1.9% | — | — | 4.0 | — | 25,845 | 18,427 | 7,418 | 71.3% | 28.7% | 972 | 98.8% | 1.2% | — | — | 2.0 | — | View source ↗ |
| Wellcare Medicare Advantage (H2775)Medicare Advantage | Centene Corporation | 151,140 | 126,266 | 24,874 | 83.5% | 16.5% | 2,224 | 94.2% | 5.8% | 0.0% | 100.0% | 4.0 | 1.0 | 21,698 | 18,478 | 3,220 | 85.2% | 14.8% | 362 | 97.0% | 3.0% | 0.0% | 100.0% | 1.0 | 1.0 | View source ↗ |
| EmblemHealth | ||||||||||||||||||||||||||
| EmblemHealth Medicaid and HARPMedicaid MCO | EmblemHealth | 115,230 | 89,303 | 25,927 | 77.5% | 22.5% | — | — | — | — | — | 2.1 | 57.0 | 5,302 | 4,576 | 726 | 86.3% | 13.7% | — | — | — | — | — | 0.5 | 11.0 | View source ↗ |
| EmblemHealth Child Health PlusCHIP | EmblemHealth | 6,070 | 4,983 | 1,087 | 82.1% | 17.9% | — | — | — | — | — | 2.1 | 22.5 | 122 | 101 | 21 | 82.8% | 17.2% | — | — | — | — | — | — | — | View source ↗ |
| EmblemHealth Medicare PPO (H5991)Medicare Advantage | EmblemHealth | 5,009 | 4,308 | 701 | 86.0% | 14.0% | — | — | — | — | — | 1.9 | 15.0 | 154 | 126 | 28 | 81.8% | 18.2% | — | — | — | — | — | 0.6 | 3.0 | View source ↗ |
| EmblemHealth Medicare HMO (H3330)Medicare Advantage | EmblemHealth | 73,246 | 67,626 | 5,620 | 92.3% | 7.7% | — | 0.5% | 99.5% | — | — | 1.3 | 17.0 | 2,958 | 2,497 | 461 | 84.4% | 15.6% | — | — | — | — | — | 0.4 | 4.5 | View source ↗ |
| Excellus BlueCross BlueShield | ||||||||||||||||||||||||||
| Excellus BCBS Medicare DSNP HMO (H7524)Medicare Advantage | Excellus BlueCross BlueShield | 2,327 | 1,645 | 682 | 70.7% | 29.3% | 27 | 22.2% | 77.8% | — | — | 1.8 | 1.0 | 29 | 24 | 5 | 82.8% | 17.2% | — | — | — | — | — | 0.7 | 0.8 | View source ↗ |
| Excellus BCBS Managed MedicaidMedicaid MCO | Excellus BlueCross BlueShield | 126,221 | 107,238 | 18,983 | 85.0% | 15.0% | 705 | 18.4% | 81.6% | 88.3% | 11.7% | 1.4 | 1.2 | 918 | 686 | 232 | 74.7% | 25.3% | — | — | — | — | — | 0.7 | 0.3 | View source ↗ |
| Excellus BCBS Child Health PlusCHIP | Excellus BlueCross BlueShield | 18,319 | 15,667 | 2,652 | 85.5% | 14.5% | 112 | 14.3% | 85.7% | 86.5% | 13.5% | 1.6 | 1.4 | 73 | 60 | 13 | 82.2% | 17.8% | — | — | — | — | — | 0.6 | 0.1 | View source ↗ |
| Excellus BCBS Medicare PPO (H3335)Medicare Advantage | Excellus BlueCross BlueShield | 117,729 | 110,482 | 7,247 | 93.8% | 6.2% | 1,445 | 28.9% | 71.1% | — | — | 1.0 | 0.0 | 6,240 | 5,288 | 952 | 84.7% | 15.3% | — | — | — | — | — | 0.6 | 0.2 | View source ↗ |
| Excellus BCBS Medicare HMO (H3351)Medicare Advantage | Excellus BlueCross BlueShield | 103,135 | 98,076 | 5,059 | 95.1% | 4.9% | 916 | 30.2% | 69.8% | — | — | 0.9 | 0.0 | 5,092 | 4,278 | 814 | 84.0% | 16.0% | — | — | — | — | — | 0.6 | 0.2 | View source ↗ |
| Healthfirst | ||||||||||||||||||||||||||
| Healthfirst Child Health PlusCHIP | Healthfirst | 28,487 | 20,433 | 8,054 | 71.7% | 28.3% | 869 | 3.1% | 96.9% | 0.0% | 100.0% | 2.1 | 1.0 | 513 | 302 | 211 | 58.9% | 41.1% | — | — | — | 0.0% | 100.0% | 0.4 | 0.0 | View source ↗ |
| Healthfirst Medicaid Managed CareMedicaid MCO | Healthfirst | 750,763 | 603,021 | 147,742 | 80.3% | 19.7% | 12,073 | 14.3% | 85.7% | 0.3% | 99.7% | 1.6 | 0.0 | 10,464 | 6,231 | 4,233 | 59.5% | 40.5% | — | — | — | 0.0% | 100.0% | 0.4 | 0.0 | View source ↗ |
| Healthfirst HARPMedicaid MCO | Healthfirst | 54,478 | 46,120 | 8,358 | 84.7% | 15.3% | 958 | 21.1% | 78.9% | 0.3% | 99.7% | 1.6 | 0.0 | 546 | 356 | 190 | 65.2% | 34.8% | — | — | — | 0.0% | 100.0% | 0.3 | 0.0 | View source ↗ |
| Healthfirst MLTCMedicaid MCO | Healthfirst | 30,359 | 26,471 | 3,888 | 87.2% | 12.8% | 309 | 10.4% | 89.6% | 0.0% | 100.0% | 2.1 | 0.0 | 66 | 50 | 16 | 75.8% | 24.2% | — | — | — | 0.0% | 100.0% | 0.9 | 0.5 | View source ↗ |
| Healthfirst Medicare (H9678)Medicare Advantage | Healthfirst | 11,134 | 9,989 | 1,145 | 89.7% | 10.3% | 166 | 92.8% | 7.2% | 0.0% | 100.0% | 1.5 | 0.0 | 207 | 175 | 32 | 84.5% | 15.5% | — | — | — | 0.0% | 100.0% | 0.3 | 0.0 | View source ↗ |
| Healthfirst Medicare (H5989)Medicare Advantage | Healthfirst | 52,494 | 47,266 | 5,228 | 90.0% | 10.0% | 507 | 90.3% | 9.7% | 0.0% | 100.0% | 1.4 | 0.0 | 674 | 559 | 115 | 82.9% | 17.1% | — | — | — | 0.0% | 100.0% | 0.3 | 0.0 | View source ↗ |
| Healthfirst Medicare (H1722)Medicare Advantage | Healthfirst | 3,316 | 2,998 | 318 | 90.4% | 9.6% | 49 | 95.9% | 4.1% | 0.0% | 100.0% | 1.7 | 0.0 | 71 | 58 | 13 | 81.7% | 18.3% | — | — | — | 0.0% | 100.0% | 0.4 | 0.0 | View source ↗ |
| Healthfirst Medicare HMO (H3359)Medicare Advantage | Healthfirst | 764,446 | 701,699 | 62,747 | 91.8% | 8.2% | 7,292 | 85.9% | 14.1% | 0.0% | 100.0% | 1.5 | 0.0 | 6,956 | 5,911 | 1,045 | 85.0% | 15.0% | — | — | — | 0.0% | 100.0% | 0.3 | 0.0 | View source ↗ |
| Healthfirst Medicaid Advantage Plus (Medicaid-Only Services)Medicaid MCO | Healthfirst | 70,748 | 68,477 | 2,271 | 96.8% | 3.2% | 0 | — | — | 0.0% | 100.0% | 2.0 | 0.0 | 138 | 134 | 4 | 97.1% | 2.9% | 0 | — | — | 0.0% | 100.0% | 0.8 | 0.8 | View source ↗ |
| Highmark | ||||||||||||||||||||||||||
| New York Medicaid/CHIP FFS (via Highmark)Medicaid FFS | Highmark | — | — | — | 91.3% | 8.7% | — | 39.9% | 60.1% | — | — | 2.0 | 2.0 | — | — | — | 94.6% | 5.4% | — | — | — | — | — | 1.0 | 1.0 | View source ↗ |
| Humana Inc. | ||||||||||||||||||||||||||
| Humana Health Company of New York (H3533)Medicare Advantage | Humana Inc. | 45,243 | 41,227 | 4,016 | 91.1% | 8.9% | 102 | 66.7% | 33.3% | 0.0% | 0.0% | 1.0 | 0.0 | 1,494 | 1,310 | 184 | 87.7% | 12.3% | — | — | — | 0.0% | 0.0% | 0.3 | 0.0 | View source ↗ |
| Independent Health | ||||||||||||||||||||||||||
| Independent Health Medicaid/Essential/CHPMedicaid MCO | Independent Health | 36,266 | 26,040 | 10,226 | 71.8% | 28.2% | — | — | — | 0.7% | 99.3% | 2.3 | 1.0 | 3,683 | 3,424 | 259 | 93.0% | 7.0% | — | — | — | 0.0% | 100.0% | 0.1 | 0.0 | View source ↗ |
| Independent Health Medicare (H3344)Medicare Advantage | Independent Health | 6,688 | 5,936 | 752 | 88.8% | 11.3% | — | — | — | 0.0% | 100.0% | 2.3 | 0.0 | 593 | 523 | 70 | 88.2% | 11.8% | — | — | — | 0.0% | 100.0% | 0.4 | 0.0 | View source ↗ |
| Independent Health Medicare (H3362)Medicare Advantage | Independent Health | 117,495 | 106,965 | 10,530 | 91.0% | 9.0% | — | — | — | 0.0% | 100.0% | 2.0 | 0.0 | 10,520 | 9,622 | 898 | 91.5% | 8.5% | — | — | — | 0.0% | 100.0% | 0.3 | 0.0 | View source ↗ |
| MVP Health Care | ||||||||||||||||||||||||||
| MVP Health Plan Medicaid Managed CareMedicaid MCO | MVP Health Care | 3,663 | 2,118 | 1,545 | 57.8% | 42.2% | — | — | — | — | — | — | — | 375 | 229 | 146 | 61.1% | 38.9% | — | — | — | — | — | — | — | View source ↗ |
| MVP Health Plan HARPMedicaid MCO | MVP Health Care | 344 | 228 | 116 | 66.3% | 33.7% | — | — | — | — | — | — | — | 46 | 23 | 23 | 50.0% | 50.0% | — | — | — | — | — | — | — | View source ↗ |
| MVP Health Plan Medicare (H3305)Medicare Advantage | MVP Health Care | 8,476 | 7,000 | 1,476 | 82.6% | 17.4% | — | — | — | — | — | — | — | 1,716 | 1,302 | 414 | 75.9% | 24.1% | — | — | — | — | — | — | — | View source ↗ |
| MVP Health Plan DSNP (H9615)Medicare Advantage | MVP Health Care | 8,451 | 7,453 | 998 | 88.2% | 11.8% | — | — | — | — | — | — | — | 1,746 | 1,339 | 407 | 76.7% | 23.3% | — | — | — | — | — | — | — | 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