State Detail
Virginia
5 plans reporting · CY 2025
Across 5 plans reporting in Virginia, standard prior authorization denial rates range from 5.1% to 22.1%, averaging 13.7%. Among plans reporting appeal outcomes, 28.8% 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 |
| Humana Inc. | ||||||||||||||||||||||||||
| Humana Healthy Horizons VirginiaMedicaid MCO | Humana Inc. | 32,969 | 29,118 | 3,851 | 88.3% | 11.7% | 39 | 17.9% | 82.0% | 100.0% | 0.0% | 3.1 | 1.0 | 2,275 | 1,462 | 813 | 64.3% | 35.7% | — | — | — | — | — | 0.8 | 0.2 | View source ↗ |
| Sentara Health Plans | ||||||||||||||||||||||||||
| Sentara Health Plans - Virginia Medicaid MCOMedicaid MCO | Sentara Health Plans | 228,807 | 183,059 | 45,748 | 80.0% | 20.0% | 1,363 | 32.5% | 67.5% | 0.0% | 100.0% | 6.4 | 5.0 | 121,645 | 105,748 | 15,897 | 86.9% | 13.1% | — | — | — | 0.0% | 100.0% | 1.1 | 0.9 | View source ↗ |
| Sentara Health Plans - Virginia Commercial (QHP)Exchange Plans | Sentara Health Plans | 120,290 | 108,452 | 11,838 | 90.2% | 9.8% | 127 | 44.1% | 55.9% | 0.0% | 100.0% | 4.0 | 2.0 | 16,746 | 16,169 | 577 | 96.5% | 3.5% | — | — | — | 0.0% | 100.0% | 0.8 | 0.0 | View source ↗ |
| Sentara Health Plans - Virginia Medicare AdvantageMedicare Advantage | Sentara Health Plans | 49,506 | 46,995 | 2,511 | 94.9% | 5.1% | — | — | — | 0.0% | 100.0% | 4.8 | 2.0 | 5,527 | 5,371 | 156 | 97.2% | 2.8% | — | — | — | 0.0% | 100.0% | 0.9 | 0.2 | View source ↗ |
| UnitedHealth Group | ||||||||||||||||||||||||||
| UnitedHealthcare Community Plan of Virginia (Cardinal Care Medicaid)Medicaid MCO | UnitedHealth Group | 111,870 | 87,089 | 24,781 | 77.8% | 22.1% | 1,378 | 20.8% | 79.2% | 1.4% | 98.6% | 2.2 | 1.0 | 19,421 | 14,090 | 5,331 | 72.5% | 27.4% | — | — | — | — | — | 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