State Detail
Wisconsin
15 plans reporting · CY 2025
Across 15 plans reporting in Wisconsin, standard prior authorization denial rates range from 2.0% to 17.5%, averaging 10.2%. Among plans reporting appeal outcomes, 35.1% 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 |
| Group Health Cooperative of South Central Wisconsin | ||||||||||||||||||||||||||
| GHC-SCW Qualified Health PlanExchange Plans | Group Health Cooperative of South Central Wisconsin | — | — | — | 97.0% | 3.0% | 4 | 25.0% | 75.0% | 0.0% | 100.0% | 1.0 | 0.0 | — | — | — | 97.0% | 3.0% | — | — | — | 0.0% | 100.0% | 0.2 | 0.0 | View source ↗ |
| GHC-SCW BadgerCare Plus MedicaidMedicaid MCO | Group Health Cooperative of South Central Wisconsin | — | — | — | 98.0% | 2.0% | 0 | 0.0% | 0.0% | 0.0% | 100.0% | 1.2 | 0.0 | — | — | — | 99.0% | 1.0% | — | — | — | 0.0% | 100.0% | 0.4 | 0.0 | View source ↗ |
| iCare/Humana | ||||||||||||||||||||||||||
| iCare WI Medicaid (Aggregate)Medicaid MCO | iCare/Humana | 17,526 | 15,095 | 2,431 | 86.1% | 13.9% | 49 | 14.3% | 85.7% | — | — | 5.0 | 2.0 | 714 | 567 | 147 | 79.4% | 20.6% | — | — | — | — | — | 0.8 | 0.2 | View source ↗ |
| iCare Medicare D-SNP (H2237)Medicare Advantage | iCare/Humana | 4,424 | 3,997 | 427 | 90.3% | 9.7% | 12 | 33.3% | 66.7% | — | — | 5.0 | 5.0 | 32 | 24 | 8 | 75.0% | 25.0% | — | — | — | — | — | 0.3 | 0.0 | View source ↗ |
| Molina Healthcare | ||||||||||||||||||||||||||
| Molina Healthcare of WisconsinExchange Plans | Molina Healthcare | — | — | — | 87.0% | 13.0% | — | 50.0% | 50.0% | 53.0% | 47.0% | 5.0 | 4.0 | — | — | — | 90.0% | 10.0% | — | 46.0% | 54.0% | 57.0% | 43.0% | 1.0 | 1.0 | View source ↗ |
| Network Health | ||||||||||||||||||||||||||
| Network Health MSA Network Prime (H1181)Medicare Advantage | Network Health | 790 | 652 | 138 | 82.5% | 17.5% | 0 | — | — | 0.0% | 100.0% | 3.0 | 2.0 | 34 | 32 | 2 | 94.1% | 5.9% | — | — | — | 0.0% | 100.0% | 2.0 | 1.0 | View source ↗ |
| Network Health ACA QHPExchange Plans | Network Health | 11,043 | 9,509 | 1,534 | 86.1% | 13.9% | 17 | 58.8% | 41.2% | 0.0% | 100.0% | 4.0 | 1.5 | 415 | 316 | 99 | 76.1% | 23.9% | — | — | — | 0.0% | 100.0% | 2.0 | 1.5 | View source ↗ |
| Network Health Choice PPO (H5215)Medicare Advantage | Network Health | 122,707 | 107,708 | 14,999 | 87.8% | 12.2% | 501 | 64.1% | 35.9% | 0.0% | 100.0% | 3.0 | 2.0 | 2,257 | 1,938 | 319 | 85.9% | 14.1% | — | — | — | 0.0% | 100.0% | 2.0 | 2.0 | View source ↗ |
| Quartz Health Solutions | ||||||||||||||||||||||||||
| Quartz ACA QHPExchange Plans | Quartz Health Solutions | 1,940 | 1,604 | 336 | 82.7% | 17.3% | 79 | 45.6% | 54.4% | 0.0% | 100.0% | 4.0 | 3.0 | 698 | 635 | 63 | 91.0% | 9.0% | 0 | — | — | 0.0% | 100.0% | 2.0 | 1.0 | View source ↗ |
| Quartz WI BadgerCare Plus/SSI MedicaidMedicaid MCO | Quartz Health Solutions | 12,683 | 11,643 | 1,040 | 91.8% | 8.2% | 30 | 33.3% | 66.7% | 0.0% | 100.0% | 2.1 | 0.0 | 649 | 616 | 33 | 94.9% | 5.1% | 0 | — | — | 0.0% | 100.0% | 0.7 | 0.0 | View source ↗ |
| Quartz Medicare Advantage (H9834)Medicare Advantage | Quartz Health Solutions | 11,593 | 10,855 | 738 | 93.6% | 6.4% | 71 | 26.8% | 73.2% | — | — | 1.7 | 0.0 | 262 | 233 | 29 | 88.9% | 11.1% | 0 | — | — | 0.0% | 100.0% | 0.9 | 0.0 | View source ↗ |
| Security Health Plan | ||||||||||||||||||||||||||
| Security Health Plan Individual (QHP)Exchange Plans | Security Health Plan | 6,765 | 5,856 | 909 | 86.6% | 13.4% | — | — | — | — | — | 1.6 | 0.0 | 1,147 | 1,063 | 84 | 92.7% | 7.3% | — | — | — | — | — | 0.7 | 0.2 | View source ↗ |
| Security Health Plan BadgerCare/SSI MedicaidMedicaid MCO | Security Health Plan | 14,980 | 13,149 | 1,831 | 87.8% | 12.2% | — | — | — | — | — | 1.0 | 0.1 | 2,757 | 2,537 | 220 | 92.0% | 8.0% | — | — | — | — | — | 0.6 | 0.2 | View source ↗ |
| Security Health Plan Medicare AdvantageMedicare Advantage | Security Health Plan | 58,357 | 54,931 | 3,426 | 94.1% | 5.9% | — | — | — | — | — | 0.7 | 0.0 | 12,689 | 11,735 | 954 | 92.5% | 7.5% | — | — | — | — | — | 0.5 | 0.2 | View source ↗ |
| Wisconsin Department of Health Services | ||||||||||||||||||||||||||
| Wisconsin Medicaid Fee-for-ServiceMedicaid FFS | Wisconsin Department of Health Services | 165,012 | 148,796 | 6,556 | 90.2% | 4.0% | — | — | — | 0.0% | 100.0% | 3.1 | 1.0 | 10 | 9 | 0 | 90.0% | 0.0% | — | — | — | 0.0% | 100.0% | 6.3 | 2.8 | 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