March 31, 2026 was the first deadline under CMS-0057-F for Medicare Advantage organizations, Medicaid and CHIP managed care plans and federal exchange QHP issuers to post prior authorization approval rates, denial rates, appeal outcomes and decision turnaround times on their public websites, covering calendar year 2025.

The baseline those disclosures land on: KFF counts roughly 50.2 million MA determinations in 2024 at a 7.7% denial rate, with 80.7% of appealed denials overturned.

Key Takeaways

  • 50.2 million MA determinations in 2024 at a 7.7% denial rate, up from 6.4% in 2023 and 5.7% in 2019, so denial frequency has shifted structurally rather than cyclically.
  • More than 8 percentage points separate the lowest and highest denial rates among major MA insurers, a spread that was proprietary before March 2026 and is now published.
  • 80.7% of appealed denials overturned, reaching 95.3% to 95.5% at Centene and 92.6% at CVS Health.
  • 11.5% of denied requests were appealed, so the overturn rate is measured on roughly one denial in nine.
  • 72 hours expedited, seven calendar days standard replaced the prior 14-day window from January 2026, with FHIR API requirements following in January 2027.

What Is Now Public

The rule splits into an operational phase already in force and an API phase arriving next January.

Since January 2026 the impacted payers, excluding federal exchange QHP issuers, must decide expedited requests within 72 hours and standard requests within seven calendar days, against a previous standard allowing up to 14 days, and must give a specific clinical rationale on denial rather than a generic coverage policy citation. The annual disclosure covers four metrics: approval rate, denial rate, share of denials approved on appeal, and average time from submission to determination.

Reporting granularity differs by segment. MA organizations report at contract level, state Medicaid and CHIP fee-for-service at state level, managed care entities at plan level, and exchange issuers at issuer level. Drug prior authorizations are outside the current requirement.

By January 2027 payers must stand up four FHIR-based APIs on HL7 standards covering prior authorization submission and status, patient access, provider access and payer-to-payer exchange. CMS estimates roughly $15 billion of system-wide savings over 10 years, which matters most at the estimated 65% of medical plans that lacked fully electronic prior authorization capability going into 2026.

The Spread Was the Confidential Part

Publishing four metrics does not change any plan's utilization management. Publishing them next to each other does.

Insurer PA Requests per Enrollee Denial Rate Appeal Rate (% of Denials) Overturn Rate (% of Appeals)
Elevance Health 2.7 - 3.0 4.1 - 4.2% 9.1% 87.9%
Humana 2.1 - 2.2 5.5% 11.6% 64.7%
UnitedHealth Group 0.9 - 1.0 12.6 - 12.8% 12.0% 78.8%
CVS Health (Aetna) 1.1 11.6% 19.9 - 21.4% 92.6%
Centene 2.7 - 2.9 11.9 - 12.3% 7.5% 95.3 - 95.5%
Kaiser 0.6 10.3% 1.6 - 1.7% 50.2%

Two philosophies are visible in the same table. UnitedHealth Group submits the fewest requests per enrollee, 0.9 to 1.0, at the highest denial rate of 12.6% to 12.8%. Elevance Health runs the opposite configuration, 2.7 to 3.0 requests per enrollee at 4.1% to 4.2% denials. Narrow scope with high denial intensity and broad scope with liberal approval produce similar-looking savings and very different public numbers.

Convergence pressure comes from three directions at once: regulators identifying outliers where a high denial rate sits beside a high overturn rate, providers using the data in network negotiations, and members in MA and exchange markets choosing annually.

The cost of moving is calculable. Take a plan with 500,000 members at 1.7 requests per member going from a 12% denial rate to 7%: that is roughly 42,500 additional approvals a year. At $2,000 to $4,000 per authorized service the incremental medical cost runs $85 million to $170 million, or about $170 to $340 per member per year, and it belongs in the 2027 and 2028 filings as an explicit layer rather than inside base trend.

Two other adjustments run alongside it. Faster turnaround pulls forward care that was previously delayed or abandoned, which shows up as a one-time step in authorized volume rather than a repeating trend. And prior authorization removal has its own effect: UnitedHealthcare announced in May 2026 it would drop the requirement for 30% of services by year-end, and 48 insurers through AHIP committed to an aggregate 11% reduction in medical prior authorizations and 15% in MA.

The Denials Nobody Contests

The published metrics describe the denials that were tested. The larger number is the ones that were not.

Only 11.5% of denied MA prior authorization requests were appealed in 2024, and 80.7% of that fraction was overturned. The remaining share was never contested, so nothing in the disclosure says whether those denials would have survived review. Some of that care was legitimately inappropriate. Given the reversal rate on the contested subset, some of it was not, and in Medicaid managed care, where appeal rates are lower still, the untested share is proportionally larger.

The HHS Office of Inspector General documented the mechanism in 2022, finding that some MA organizations denied requests meeting Medicare coverage criteria. What the new data adds is the ability to see which plans, at what rate, next to their peers.

Two extensions will widen the picture and complicate it. The CMS-0062-P proposed rule published in April 2026 would carry the same framework into pharmacy, where the numbers are different in kind: Illinois Medicaid data shows pharmacy approval rates below 60% against 90% and above for medical services. And the January 2027 API cutover concentrates its own disruption, with pent-up authorization demand moving through faster electronic channels in the first quarters of the year, which is a reserving problem before it is a pricing one.

Further Reading