News: Prior authorization reporting requirements show high denial rates, new data reveals

New data from KFF shows insurers denied up to 18% of prior authorization (PA) requests in 2025, but missing service-line detail limits the amount of actionable information available to providers.

The analysis, using newly required public disclosures, shows that health plans across insurance markets denied between 12% and 18% of standard PA requests in 2025. The disclosures offer new insights into PA volume but also reveal reporting limitations restrict the amount of actionable service-line data available to health systems.

Across three segments—Medicare Advantage (MA), Medicaid managed care, and Affordable Care Act (ACA) Marketplace plans—payers denied at least one in eight standard requests. Denial rates varied widely depending on the payer and market:

• ACA Marketplaces: Payers reported the highest denial frequency, rejecting 18% of standard PA requests and 16% of expedited requests.
• Medicaid Managed Care: Plans denied 14% of standard PA requests and 12% of expedited requests.
• MA: Plans denied 12% of standard PA requests and 10% of expedited requests.

The public disclosures stem from the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) published in February 2024 designed to improve electronic data exchange and streamline PA workflows. The rule mandates that MA organizations, state Medicaid and Children’s Health Insurance Program (CHIP) entities, and qualified health plan issuers on Federally Facilitated Exchanges publicly report annual PA metrics on their websites. Payers are required to disclose aggregate metrics, including total approval and denial rates alongside decision response times.

Editor’s note: To read the full report, click here. To read additional coverage from HealthLeaders, click here.