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CMS Prior Authorization Reporting - Medicare Advantage

To comply with the CMS Interoperability and Prior Authorization final rule, Louisiana Blue is required to annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year. 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.

Below are the CMS required metrics for Louisiana Blue Medicare Advantage Plans for reporting year 2025:

01/01/2025-12/31/2025 H6453 (HMO) H1248 (PPO)
The number of standard (non-urgent) prior authorization requests received 89,303 32,192
The number of standard (non-urgent) prior authorization requests approved 88,405 31,879
The percentage of standard (non-urgent) prior authorization requests that were approved 98.99% 99.03%
The number of standard (non-urgent) prior authorization requests denied 898 313
The percentage of standard (non-urgent) prior authorization requests that were denied 1.01% 0.97%
The number of standard (non-urgent) prior authorization requests for which the timeframe for review was extended and the request was approved 27 16
The percentage of standard (non-urgent) prior authorization requests for which the timeframe for review was extended and the request was approved 0.03% 0.05%
The number of appeals received on standard (non-urgent) prior authorization requests 38 17
The number of standard (non-urgent) prior authorization requests that were approved after appeal 32 17
The percentage of standard (non-urgent) prior authorization requests that were approved after appeal 84.21% 100.00%
The number of expedited (urgent) prior authorization requests received 6,851 2,952
The number of expedited (urgent) prior authorization requests approved 6,762 2,937
The percentage of expedited (urgent) prior authorization requests that were approved. 98.69% 99.49%
The number of expedited (urgent) prior authorization requests that were denied 89 15
The percentage of expedited (urgent) prior authorization requests that were denied. 1.31% 0.51%
The number of expedited (urgent) prior authorization requests for which the timeframe for review was extended  1 1
The percentage of expedited (urgent) prior authorization requests for which the timeframe for review was extended and the request was approved 0.01% 0.03%
The average time that elapsed between the submission of a prior authorization request and a determination for standard (non-urgent) prior authorizations.* < 1 day 1 day
The median time that elapsed between the submission of a prior authorization request and a determination for standard (non-urgent) prior authorizations < 1 day < 1 day
The average time that elapsed between the submission of a prior authorization request and a determination for expedited (urgent) prior authorizations.* 5 hours 5 hours
The median time that elapsed between the submission of a prior authorization request and a determination for expedited (urgent) prior authorizations. 1 hour 1 hour
*42 CFR 422.122 Medicare Advantage Plans are required to respond to standard prior authorization requests within 7 days and expedited (urgent) requests within 72 hours
These are the medical items and services for which we require prior authorization (excluding drugs)
2025 Blue Advantage Quick Reference Guide
*These refer to 2025 items and services, and these may differ for 2026.