State Detail
Texas
11 plans reporting · CY 2025
Across 11 plans reporting in Texas, standard prior authorization denial rates range from 6.0% to 24.6%, averaging 14.0%. Among plans reporting appeal outcomes, 45.9% 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 |
| Aetna/CVS Health | ||||||||||||||||||||||||||
| Aetna Better Health TX MA (H8597)Medicare Advantage | Aetna/CVS Health | — | — | — | 87.3% | 12.7% | — | 86.3% | 13.7% | — | — | 1.8 | 0.0 | — | — | — | 83.7% | 16.3% | — | — | — | — | — | 0.4 | 0.0 | View source ↗ |
| Centene Corporation | ||||||||||||||||||||||||||
| Wellcare By Allwell Medicare Advantage (H5294)Medicare Advantage | Centene Corporation | 46,737 | 35,263 | 11,474 | 75.5% | 24.6% | 952 | 97.7% | 2.3% | 0.0% | 100.0% | 5.0 | 3.0 | 2,153 | 1,864 | 289 | 86.6% | 13.4% | 146 | 95.9% | 4.1% | 0.0% | 100.0% | 0.0 | 1.0 | View source ↗ |
| Superior HealthPlan Medicaid (STAR/STAR+PLUS/CHIP)Medicaid MCO | Centene Corporation | 315,902 | 245,755 | 70,147 | 77.8% | 22.2% | 7,316 | 51.9% | 48.1% | 5.0% | 95.1% | 3.0 | 1.0 | 7,546 | 6,211 | 1,335 | 82.3% | 17.7% | 241 | 63.1% | 36.9% | 0.0% | 100.0% | 1.0 | 1.0 | View source ↗ |
| CHRISTUS Health Plan | ||||||||||||||||||||||||||
| CHRISTUS Health Plan Medicare Advantage (PC2607)Medicare Advantage | CHRISTUS Health Plan | 399 | 365 | 36 | 91.0% | 9.0% | 2 | 0.0% | 100.0% | — | — | 3.0 | 2.0 | 27 | 27 | 0 | 100.0% | 0.0% | 0 | — | — | — | — | 1.1 | 1.0 | View source ↗ |
| Community Health Choice | ||||||||||||||||||||||||||
| Community Health Choice CHIP/CHIP-PCHIP | Community Health Choice | 2,858 | 2,383 | 475 | 83.0% | 17.0% | 41 | 56.0% | 44.0% | 45.0% | 55.0% | 9.0 | 3.0 | 232 | 193 | 39 | 83.0% | 17.0% | — | — | — | 0.0% | 100.0% | 12.0 | 3.0 | View source ↗ |
| Community Health Choice STAR/STAR+PLUS MedicaidMedicaid MCO | Community Health Choice | 52,049 | 46,046 | 6,003 | 88.0% | 12.0% | 941 | 57.0% | 43.0% | 52.0% | 48.0% | 7.0 | 4.0 | 6,374 | 5,633 | 741 | 88.0% | 12.0% | — | — | — | 55.0% | 45.0% | 8.0 | 3.0 | View source ↗ |
| Community Health Choice D-SNPMedicare Advantage | Community Health Choice | 1,430 | 1,304 | 126 | 91.0% | 9.0% | 4 | 0.0% | 100.0% | 80.0% | 20.0% | 7.0 | 5.0 | 192 | 170 | 22 | 89.0% | 11.0% | — | — | — | 100.0% | 0.0% | 4.0 | 3.0 | View source ↗ |
| Health Care Service Corporation | ||||||||||||||||||||||||||
| BCBS Texas Medicare Advantage (HCSC)Medicare Advantage | Health Care Service Corporation | — | — | — | 84.3% | 15.7% | — | 82.0% | 18.0% | — | — | 2.0 | 0.5 | — | — | — | 73.8% | 26.2% | — | — | — | — | — | 1.7 | 1.3 | View source ↗ |
| BCBS Texas MedicaidMedicaid MCO | Health Care Service Corporation | — | — | — | 89.0% | 11.0% | — | 23.4% | 76.6% | 60.7% | 39.3% | 1.8 | 2.0 | — | — | — | 77.0% | 23.0% | — | — | — | — | — | 0.9 | 1.0 | View source ↗ |
| Blue Cross and Blue Shield of Texas (Individual & Family)Exchange Plans | Health Care Service Corporation | — | — | — | 94.0% | 6.0% | — | 14.0% | 86.0% | — | — | 0.2 | 0.5 | — | — | — | 90.0% | 10.0% | — | — | — | — | — | 0.8 | 1.2 | View source ↗ |
| Kelsey-Seybold Clinic | ||||||||||||||||||||||||||
| KelseyCare Advantage Medicare AdvantageMedicare Advantage | Kelsey-Seybold Clinic | 26,316 | 22,255 | 4,061 | 84.6% | 15.4% | 190 | 36.3% | 63.7% | 0.0% | 100.0% | 1.5 | 1.0 | 5,350 | 4,023 | 1,327 | 75.2% | 24.8% | — | — | — | — | — | 0.5 | 0.2 | 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