Prior Authorization Metrics for Medical Items and Services (Excluding Drugs)
To comply with the CMS Interoperability and Prior Authorization final rule, the Alliance is required to annually report aggregated prior authorization metrics on our website.
Specifically, this includes prior authorization request data (such as approvals and denials) for all medical items and services (excluding drugs) over the previous calendar year. Please refer to this list of all medical items and services (excluding drugs) that require prior authorization.
Publicly reporting these metrics promotes transparency and accountability, helps patients understand prior authorization processes, and enables providers to evaluate payer performance. In addition, metrics can be used to compare plans, programs, and payers.
Prior Authorization Metrics for Medical Items and Services (Excluding Drugs) for CY 2025
| Count | Percent | |
|---|---|---|
| List of all items and services requiring prior authorization | 548558 | |
| Total # of routine requests for denominator for the routine percentages | 518170 | |
| Percentage of standard prior authorization requests that were approved | 510141 | 98.45% |
| Percentage of standard prior authorization requests that were denied | 8029 | 1.55% |
| Total # of requests that were appealed for denominator for approved after appeal | 434 | |
| Percentage of standard prior authorization requests that were approved after appeal | 99 | 22.81% |
| Percentage of prior authorization requests for which the timeframe for review was extended, and the request was approved | 900 | 0.16% |
| Total # of expedited requests for denominator for the urgent percentages | 30388 | |
| Percentage of expedited prior authorization requests that were approved | 30300 | 99.71% |
| Percentage of expedited prior authorization requests that were denied | 88 | 0.29% |
| Avg - day | Median - day | |
| Average and median time that elapsed between the submission of a request and a determination by the payer, plan, or issuer, for standard prior authorizations | 1.52 | 0 |
| Average and median time that elapsed between the submission of a request and a| decision by the payer, plan, or issuer, for expedited prior authorizations | 0.36 | 0 |
API Call Metrics for CY 2025
| The total number of unique patients whose data was transferred via the Patient Access API to an application of their choice | 412 |
| The total number of unique patients whose data was transferred more than once | 410 |
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