Prior authorization metrics

The Centers for Medicare and Medicaid Services (CMS) requires health plans to publicly share prior authorization approval rates and decision timeframes to increase transparency for members and providers.

Metrics are reported annually to meet the CMS Interoperability and Prior Authorization Final Rule (CMS‑0057‑F)⁠ and apply to the following plans:

• Affordable Care Act (ACA)
• Blue Medicare Advantage^℠ (HMO and PPO)
• Experience Health Medicare Advantage^℠ (HMO)
• Healthy Blue + Medicare^℠ (HMO-POS D-SNP)

Use these metrics to review how prior authorization requests were processed.

A standard request occurs when a provider requests prior authorization for a treatment or service that is not expedited or urgent. Review the metrics to understand outcomes for standard requests.

Percentages show how often standard prior authorization requests resulted in approval or denial during the reporting period.

Determination timelines show the total time between receipt of a request and the final determination. Time is measured in business days for Affordable Care Act (ACA) plans and calendar days for Medicare plans.

An expedited or urgent request is when a provider asks for faster approval because waiting could put a patient’s health at risk.

Definition for urgent for ACA plans

Blue Cross NC follows National Committee for Quality Assurance (NCQA) standards for reviewing urgent prior authorization requests for ACA plans. NCQA considers 24 hours to be equivalent to one calendar day and 72 hours to be equivalent to three calendar days. NCQA measures timeliness of notification from the date when the health insurance company receives the request from the member or the member’s authorized representative, even if the health insurance company does not have all the information necessary to make a decision, to the date when the notice was provided to the member and provider, as applicable.

Definition for expedited for Medicare Advantage plans

Blue Cross NC follows CMS guidelines for expedited prior authorization requests. Per the guidelines, a health insurance company offering Medicare Advantage plans that receives the request from the member or the member’s authorized representative for expedited determination must make its determination and notify the member (and the provider involved, as appropriate) of its decision, whether approved or denied, as quickly as the member’s health condition requires, but no later than 72 hours after receiving the request.

Percentages show how often expedited or urgent prior authorization requests resulted in approval or denial during the reporting period.

Determination timelines show the total number of hours between receipt of a request and the final determination.