Prior authorization and appeals data

Annual report

Prior authorizations for services provided from January 1, 2025 to December 31, 2025
How many prior authorization (PA) requests were authorized
How many PA requests were denied. They are sorted by healthcare service, whether there was an appeal and whether the denial was upheld or reversed after the appeal.
How many PA requests were submitted electronically and not by fax, email or another way

Service Category	Total	Approvals	Denials	Approval Rate	Electronically Submitted	Total Appeals	Upheld	Overturned
Inpatient Behavioral Health	2,183	2,075	108	95%	1,481	5	2	3
Inpatient Medical	1,064	1,056	8	99%	647	106	39	67
Outpatient Behavioral Health	3,398	3,067	331	90%	3,075	1	1	0
Outpatient Medical	76,481	69,313	7,168	91%	72,700	520	181	339
Prescription Drug	105,266	59,175	46,091	56%	88,563	573	290	283

Service Category	Total	Approvals	Denials	Approval Rate	Electronically Submitted	Total Appeals	Upheld	Overturned
Inpatient Behavioral Health	7,495	7,390	105	99%	2,510	2	1	1
Inpatient Medical	2,355	2,161	194	92%	1,503	81	36	45
Outpatient Behavioral Health	3,690	3,622	68	98%	2,411	10	6	4
Outpatient Medical	113,706	107,446	6,260	94%	109,189	1,640	494	1,146
Prescription Drug	5,432	2,807	2,625	52%	4,984	10,094	4,790	5,304

Prior authorization requests may have been denied for these reasons.

Change in treatment program
Services are not considered to be medically necessary
Patient did not meet prior authorization criteria
Incomplete information submitted by the provider to the utilization review organization
The patient is no longer covered by the plan

Includes prior authorization approvals and denials data for Medicare plans

This information meets Minnesota Statute 62M.18 requirements.

The linked Interoperability report meets Federal 422.122 Prior authorization requirements.