Prior authorization and appeals data

Prior Authorizations for Services Provided from

January 1, 2024 to December 31, 2024

This information shows:

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	1,431	1,390	41	97%	764	2	1	1
Inpatient Medical	1,777	1,748	29	98%	760	23	11	12
Outpatient Behavioral Health	1,710	1,478	232	86%	1,197	2	1	1
Outpatient Medical	48,614	41,111	7,503	85%	47,935	462	217	245
Prescription Drug	38,598	28,590	10,008	74%	33,062	790	321	469

View 2023 Blue Cross prior authorization and appeals data

Service Category	Total	Approvals	Denials	Approval Rate	Electronically Submitted	Total Appeals	Upheld	Overturned
Inpatient Behavioral Health	195	190	5	97%	93	1	0	1
Inpatient Medical	314	307	7	98%	210	3	0	3
Outpatient Behavioral Health	244	216	28	89%	197	1	1	0
Outpatient Medical	15,082	13,078	2,004	87%	14,983	68	35	33
Prescription Drug	3,653	2,830	823	77%	3,316	188	85	103

View 2023 Blue Plus prior authorization and appeals data

Reasons for denials

Prior authorization requests may have been denied for these reasons.

Blue Cross and Blue Shield of Minnesota and Blue Plus:

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

Delegates:

Did not meet prior authorization criteria
Incomplete information submitted
Inactive coverage/no plan coverage
Change in treatment program
Other

This information meets Minnesota Statute 62M.18 requirements.