State Detail
West Virginia
6 plans reporting · CY 2025
Across 6 plans reporting in West Virginia, standard prior authorization denial rates range from 2.0% to 17.0%, averaging 8.7%. Among plans reporting appeal outcomes, 63.3% 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 |
| Highmark | ||||||||||||||||||||||||||
| West Virginia Medicaid FFS (via Highmark)Medicaid FFS | Highmark | 1,426 | 1,371 | 55 | 96.0% | 4.0% | 3 | 0.0% | 100.0% | 97.0% | 80.0% | 0.5 | 0.5 | 1,381 | 1,343 | 38 | 97.0% | 3.0% | 0 | — | — | 83.0% | 17.0% | 0.5 | 0.5 | View source ↗ |
| Highmark Health Options WV (Medicaid)Medicaid MCO | Highmark | — | — | — | 98.0% | 2.0% | — | 34.0% | 66.0% | 90.0% | 10.0% | 2.1 | 2.0 | — | — | — | 97.0% | 3.0% | — | 69.0% | 31.0% | 89.0% | 11.0% | 0.5 | 0.5 | View source ↗ |
| The Health Plan | ||||||||||||||||||||||||||
| The Health Plan - WV Medicaid (Mountain Health Trust)Medicaid MCO | The Health Plan | 48,894 | 40,528 | 8,366 | 83.0% | 17.0% | 74 | 53.0% | 47.0% | — | — | 1.0 | 0.0 | 500 | 431 | 69 | 86.0% | 14.0% | 5 | 40.0% | 60.0% | — | — | 1.0 | 1.0 | View source ↗ |
| The Health Plan - WV CHIPCHIP | The Health Plan | 1,550 | 1,332 | 218 | 86.0% | 14.0% | 1 | 100.0% | 0.0% | — | — | 1.0 | 0.0 | 10 | 10 | 0 | 100.0% | 0.0% | 0 | — | — | — | — | 1.0 | 0.0 | View source ↗ |
| The Health Plan - Medicare PPO H8604 (WV)Medicare Advantage | The Health Plan | 3,514 | 3,235 | 279 | 92.0% | 8.0% | 16 | 100.0% | 0.0% | — | — | 2.8 | 1.0 | 74 | 72 | 2 | 97.0% | 3.0% | 7 | 100.0% | 0.0% | — | — | 1.5 | 1.0 | View source ↗ |
| The Health Plan - Medicare HMO H3672 (WV/SE Ohio)Medicare Advantage | The Health Plan | 10,305 | 9,583 | 722 | 93.0% | 7.0% | 46 | 93.0% | 7.0% | — | — | 3.4 | 2.0 | 141 | 132 | 9 | 94.0% | 6.0% | 22 | 100.0% | 0.0% | — | — | 1.6 | 1.0 | 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