For the first time in U.S. healthcare history, your payers are legally required to show you exactly how often they deny prior authorization requests — and what happens when you appeal. The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) set a March 31, 2026 deadline for health insurers to publicly post their calendar year 2025 PA metrics. The data is now out. And for billing teams, practice managers, and healthcare administrators, it changes the game.
Harris Secure Connect analyzed the first wave of publicly available CMS-0057-F disclosures alongside the most current KFF, OIG, AMA, and Senate findings to produce this report. Here is what the numbers show — and what your team should do about it.
What CMS-0057-F Actually Requires
Effective January 1, 2026, Medicare Advantage organizations, Medicaid MCOs, and CHIP plans must now operate under binding prior authorization timelines:
- Standard PA decisions: 7 calendar days (down from 14)
- Expedited/urgent decisions: 72 hours
- Public reporting of CY2025 PA metrics: Due March 31, 2026 — the first mandatory public reporting in history
The metrics payers must disclose include approval rates, denial rates (full and partial), appeal outcomes, and actual turnaround times — not estimates or commitments, but measured performance data. Payers who missed the March 31 deadline are in non-compliance.
One important caveat: the Trump administration suspended two additional transparency requirements in June 2025 — health equity analysis of PA practices and plan-level (vs. contract-level) reporting. This means the public data reflects aggregate performance across sometimes hundreds of plans under a single payer contract. Use these figures as directional benchmarks, not precise local performance indicators.
The Medicare Advantage Benchmark Numbers
The overall MA prior authorization denial rate is 7.7% — meaning nearly 1 in 13 of the 52.8 million PA requests submitted in 2024 was fully or partially denied. That’s 4.1 million denied requests in a single year, up from 49.8 million total requests in 2023.
The more alarming number: 80.7%. That is the MA appeal overturn rate — meaning 4 in 5 denied PA requests that were appealed were ultimately reversed. And yet only 11.5% of denials are ever appealed. Providers are leaving approved care on the table by not challenging denials they would win.
Payer-by-Payer MA Denial Rate Scorecard (2024 Data)
| Payer | PA Denial Rate | Appeal Overturn Rate | vs. 7.7% Benchmark |
|---|---|---|---|
| UnitedHealthcare | 12.8% | ~80.7% (industry avg) | ABOVE — +5.1 pts |
| Centene / WellCare | 12.3% | 95.5% | ABOVE — +4.6 pts |
| CVS / Aetna | 11.9% | ~80.7% (industry avg) | ABOVE — +4.2 pts |
| Kaiser Permanente | 10.9% | 51.0% | ABOVE — +3.2 pts |
| Industry Average | 7.7% | 80.7% | BENCHMARK |
| Humana | 5.8% | ~68.4% | BELOW — -1.9 pts |
| Elevance / Anthem | 4.2% | ~80.7% (industry avg) | BELOW — -3.5 pts |
Source: KFF analysis of CMS Medicare Advantage prior authorization data for calendar year 2024, published January 28, 2026.
Two Payers to Watch Closely
UnitedHealthcare has both the highest MA denial rate (12.8%) and the lowest PA volume per enrollee (1.0 per enrollee). That combination — few requests, many denials — is the inverse of the normal pattern. The Senate Permanent Subcommittee on Investigations has flagged UHC’s nH Predict algorithm for driving post-acute care denial rates from 8.7% (2019) to 22.7% (2022).
Centene / WellCare has a 12.3% denial rate and a 95.5% appeal overturn rate — the highest overturn rate of any major insurer. Centene’s denials are not holding up to clinical review. Every Centene denial is worth appealing.
Medicaid MCO: A Harder Road for Providers
Medicaid managed care organizations operate under a fundamentally different — and more difficult — oversight environment. The OIG baseline denial rate for Medicaid MCOs is 12.5%, more than double the MA rate at the same period. And where MA plans have a structured appeals process with automatic independent external review, most Medicaid MCOs do not — only 15 of 39 MCO states had an external review process as of mid-2024.
The result: the Medicaid appeal overturn rate is just 36%, compared to 80.7% in Medicare Advantage. And 89% of Medicaid enrollees who are denied never appeal at all. The combination of higher denial rates and lower appeal success is a significant and underreported problem for practices with Medicaid-heavy patient panels.
One additional pressure point: the One Big Beautiful Bill Act (OBBBA), signed July 4, 2025, mandates six-month Medicaid redeterminations for expansion adults with work requirements effective December 31, 2026. CBO projects 11.8 million Americans will lose coverage by 2034. Practices serving behavioral health, rural primary care, or FQHC populations should track which MCO payers are tightening PA requirements in response to shrinking Medicaid enrollment.
Turnaround Times: Where Payers Stand
The new 7-day/72-hour standards represent the most significant operational change for payers under CMS-0057-F. Before 2026, the standard was 14 days. Most major payers are now reporting compliance — though some have still not published specific turnaround time data as of early April 2026.
- CVS/Aetna: Reports 95% of eligible PAs approved within 24 hours, many instantaneous.
- Cigna: 80% of U.S. medical PAs approved within 24 hours; 53% of electronic PAs approved within minutes. Removed 345 services from its PA list (15% reduction) per its March 12, 2026 Transparency Report.
- Humana: Committed to 95%+ of complete electronic PAs decided within one business day as of January 1, 2026.
- Elevance / Anthem: Majority approved in real time via portal; does not use AI to automate denials.
- Centene and Molina: Had not published specific turnaround time data as of April 2, 2026 — one day after the mandatory deadline. Warrants monitoring.
The 80.7% Overturn Rate — What It Means Operationally
This is the number that should change how billing teams operate. The MA appeal overturn rate has held above 80% every year from 2019 through 2024. It means the majority of denied prior authorization requests are wrong — and would be reversed with an appeal. But only 1 in 9 denials is ever appealed.
The implication is direct: your team is absorbing denied care that payers would ultimately approve if challenged. For Centene specifically, with a 95.5% overturn rate, nearly every MA denial is worth appealing. For payers at or above the 80.7% threshold, building systematic appeal workflows isn’t optional — it’s revenue recovery.
Specialty Spotlight: Where PA Burden Hits Hardest
CMS-0057-F’s initial reporting cycle does not break out denial rates by service category. But Senate PSI findings, OIG reports, and payer disclosures point to four specialties bearing disproportionate burden:
Orthopedics: Step therapy requirements, physical therapy volume limits, and DME PA requirements drive friction. The opportunity: UHC’s Gold Card program and Elevance’s PA Pass program now cover hundreds of orthopedic codes for qualifying provider groups — meaning PA submission can be eliminated entirely for groups that qualify. UHC’s Gold Card program expanded 40%+ in 2025.
Oncology: The stakes are highest here — delays in chemotherapy, immunotherapy, or radiation authorization directly affect patient outcomes. Senate PSI documented post-acute cancer care denial rates 3 to 16 times higher than overall rates at UHC, Humana, and CVS. For oncology cases, always request expedited review. CMS-0057-F requires a 72-hour decision when standard timelines would jeopardize a patient’s life or health.
Behavioral Health: Federal mental health parity law (MHPAEA) requires that PA standards for behavioral health services be no more restrictive than for comparable medical and surgical services — but OIG has documented that BH services have among the highest denial rates of any category, and patients have among the lowest appeal rates. If your payer’s BH denial rates materially exceed their medical/surgical rates, that’s a legally actionable parity violation.
Cardiology: Burden concentrates in pre-procedure diagnostic imaging (stress tests, echocardiograms, nuclear studies) and post-procedure SNF and cardiac rehabilitation transitions. Senate PSI specifically flagged post-acute cardiac care at UHC and Humana as denial hot spots.
Action Items for Your Billing Team
This week:
- Pull your own denial data by payer for the past 12 months. Compare your payer-specific rates against the benchmarks above. If your UHC MA denial rate exceeds 12.8%, you have a documented problem to address.
- For Centene: establish a standing appeal protocol now. Their 95.5% overturn rate means nearly every denial is reversible.
- Check Gold Card (UHC) and PA Pass (Elevance) eligibility for your group. If you qualify, you can eliminate PA submission for hundreds of codes entirely.
- Verify whether your top Medicaid MCO payers have posted CMS-0057-F data. If Centene or Molina plans have not posted, monitor their websites directly.
Within 30 days:
- Build payer-tier appeal response protocols grouped by denial rate and overturn data: Tier 1 (highest denial + highest overturn = appeal everything), Tier 2 (moderate), Tier 3 (lowest friction). Allocate staff time accordingly.
- Update appeal templates to cite CMS-0057-F benchmarks. Contextualizing a denial against the published industry overturn rate changes how peer-to-peer reviewers receive it.
- If you serve a Medicaid behavioral health population: audit denial rates by payer and file parity complaints where BH denial rates materially exceed medical/surgical rates.
- Review your clearinghouse PA submission workflows. Clean, complete PA requests with all required clinical documentation are your most cost-effective denial prevention tool.
Ongoing:
- Calendar March 31, 2027 — the next CMS-0057-F reporting cycle deadline (CY2026 data).
- Watch for the FHIR-based Prior Authorization API mandates effective January 1, 2027. Your clearinghouse needs to be ready to connect to these APIs.
- Use payer PA data in contract renegotiations. Published denial rates above benchmark give you documented evidence to request process improvements as a condition of contract renewal.
What Comes Next
The CMS-0057-F reporting cycle has just begun. The data published for CY2025 is imperfect — contract-level rather than plan-level, incomplete in some cases, and still being indexed. But the trajectory is clear: payer PA behavior is now on the public record, and it will only become more granular over time. Practices and billing teams that build systems around this data now — tracking their own denial rates against published benchmarks, appealing systematically, and monitoring payer behavior across reporting cycles — will be measurably better positioned than those that don’t.
The era of payers operating their PA programs behind closed doors is over.
Data in this analysis is sourced from KFF analysis of CMS Medicare Advantage prior authorization data (January 28, 2026), the HHS Office of Inspector General (July 2023), the Senate Permanent Subcommittee on Investigations (October 2024), the Cigna Group 2025 Customer Transparency Report (March 12, 2026), the American Medical Association 2024–2025 prior authorization surveys, and individual payer public disclosures. CMS-0057-F CY2025 payer-published data incorporated where available as of April 2, 2026.
Is Your Clearinghouse Working as Hard as Your Billing Team?
Harris Secure Connect has served healthcare billing teams for 25+ years. Our advanced claim scrubbing tools catch the documentation gaps and coding issues that payers use to justify denials — before claims leave your building. Fewer denials means fewer appeals, faster payment, and less administrative burden on your staff.
As the FHIR-based PA API mandates approach in 2027, your clearinghouse partner needs to be ahead of the curve — not catching up to it. Schedule a demo to see how Harris Secure Connect can reduce your prior authorization burden.
