State Detail
Pennsylvania
6 plans reporting · CY 2025
Across 6 plans reporting in Pennsylvania, standard prior authorization denial rates range from 2.0% to 21.0%, averaging 9.4%. Among plans reporting appeal outcomes, 50.4% 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 |
| Capital Blue Cross | ||||||||||||||||||||||||||
| Capital Blue Cross CHIPCHIP | Capital Blue Cross | 864 | 685 | 179 | 79.0% | 21.0% | 0 | — | — | 43.0% | 57.0% | 42.0 | 0.0 | 66 | 55 | 11 | 83.0% | 17.0% | 0 | — | — | — | — | 1.0 | 1.0 | View source ↗ |
| Geisinger Health Plan | ||||||||||||||||||||||||||
| Geisinger Gold Medicare AdvantageMedicare Advantage | Geisinger Health Plan | — | — | — | 98.0% | 2.0% | 149 | 47.6% | 52.4% | 0.0% | 100.0% | 0.6 | 0.0 | — | — | — | 96.1% | 3.9% | — | — | — | — | — | 0.3 | 0.0 | View source ↗ |
| Highmark | ||||||||||||||||||||||||||
| Highmark PA DSNP Medicare Advantage (H5932)Medicare Advantage | Highmark | 7,010 | 6,152 | 857 | 88.0% | 12.0% | 440 | 72.0% | 28.0% | 100.0% | 0.0% | 4.7 | 5.5 | 11,889 | 10,887 | 1,002 | 92.0% | 8.0% | 345 | 77.0% | 23.0% | 90.0% | 10.0% | 0.5 | 0.5 | View source ↗ |
| Highmark QHP (FFE)Exchange Plans | Highmark | 120,652 | 111,548 | 9,104 | 92.0% | 8.0% | 43 | 47.0% | 53.0% | 98.0% | 2.0% | 0.5 | 0.5 | 23,514 | 21,465 | 2,049 | 91.0% | 9.0% | 2 | 100.0% | 0.0% | 95.0% | 5.0% | 0.5 | 0.5 | View source ↗ |
| Pennsylvania Medicaid/CHIP FFS (via Highmark)Medicaid FFS | Highmark | 22,141 | 21,291 | 850 | 96.0% | 4.0% | 1,744 | 35.0% | 65.0% | 90.0% | 10.0% | 1.5 | 0.5 | 15,156 | 14,730 | 425 | 97.0% | 3.0% | 110 | 73.0% | 27.0% | 91.0% | 9.0% | 0.5 | 0.5 | View source ↗ |
| UPMC Health Plan | ||||||||||||||||||||||||||
| UPMC for You (Medicaid)Medicaid MCO | UPMC Health Plan | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | — | 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