02 · Denials
Who says no, and what happens next
1,798,286 standard requests were denied across the 19 filings in Medicaid FFS that publish counts (of 22), a 20.6% rateⓘ. Four ways to read that number: whether urgent requests fare better or worse and how long decisions take, who issued the denials, whether size changes the rate, and how many denials were ever tested on appeal.
01 · Urgent requests and the clock
When the request is urgent
Expedited requests are the ones a doctor marked as time-critical, and the rule puts a clock on both kinds of decisionⓘ. Four pictures of what payers published against it: how long standard and expedited decisions actually take, whether urgent requests are denied more often than routine ones, and whether a filing's own mean and median tell the same story.
4
of 8 filings deny expedited requests more often than standard ones
2
publish a standard mean over 7 days the filings
4
publish an expedited mean over 72 hours the filings
10
publish a mean more than three times their own median, or the reverseⓘ
Standard decisions click a bar for its filings
Published mean time to decision, against the 7-day clock · 21 filings publish one
3
2
12
2
2
0–1
1–2
2–3
3–5
5–7
over 7
days; the orange bar is past the clock.
Expedited decisions click a bar for its filings
Published mean time to decision, against the 72-hour clock · 13 filings publish one
1
1
2
4
1
4
0–6
6–12
12–24
24–48
48–72
over 72
hours; the orange bar is past the clock.
Urgent against routine, 8 filings with 100+ expedited requests click a point for the filing
Standard denial rate across, expedited denial rate up, both to 30%. The dashed line is where the two agree; every point above it is a plan that says no more often when the doctor said it was urgent.
08%15%23%30% standard denial rate
● 4 deny urgent requests more often
● 4 deny them less often
The widest gaps
Percentage points by which the expedited rate exceeds the standard rate in the same filing.
Standard: mean against median click a point for the filing
The two figures a filing publishes for the same standard decisions. Median across, mean up, both on a log scale. On the dashed line the two agree; far from it, one filing's two figures do not.
the clock — 7 days, both axes
0110100 days
● mean past the clock
● mean and median three times apart
● 20 filings publish both
● 2 published a zero — drawn on the axis
Expedited: mean against median click a point for the filing
The two figures a filing publishes for the same expedited decisions. Median across, mean up, both on a log scale. On the dashed line the two agree; far from it, one filing's two figures do not.
the clock — 72 hours, both axes
01101001000 hours
● mean past the clock
● mean and median three times apart
● 12 filings publish both
● 2 published a zero — drawn on the axis
The filings behind the charts
Expedited denied more often than standard, the widest gaps
Plan
Organization
Standard
Expedited
Std mean · median
Exp mean · median
Gap
Connecticut Medicaid (HUSKY) FFS - Medical Medicaid FFS
Connecticut DSS
6.4%
13.4%
2.0 · 0.0 d
32.0 · 3.0 h
+7.0 pts
Health First Colorado / CHP+ (13 PA programs combined) Medicaid FFS
Colorado HCPF
22.3%
27.6%
5.6 · 1.5 d
26.4 · 10.3 h
+5.3 pts
Virginia Medicaid Fee-for-Service (Cardinal Care FFS) Medicaid FFS
Virginia DMAS
24.4%
26.4%
5.2 · —
75.8 · —
+2.0 pts
Connecticut Medicaid (HUSKY) FFS - Behavioral Health Medicaid FFS
Connecticut DSS
0.8%
1.1%
1.6 · 0.0 d
6.4 · 0.4 h
+0.3 pts
Against the clock, and against themselves
Plan
Organization
Standard
Expedited
Std mean · median
Exp mean · median
Flag
Mississippi Medicaid Fee-for-Service Medicaid FFS
Mississippi Division of Medicaid
—
—
3.1 · 1.0 d
110.3 · 27.0 h
expedited mean over 72 hours
mean and median three times apart
mean and median three times apart
mean and median three times apart
mean and median three times apart
California Children's Services (CCS) Medicaid FFS
California DHCS
—
—
9.0 · 2.0 d
— · —
standard mean over 7 days
mean and median three times apart
mean and median three times apart
Wisconsin Medicaid (ForwardHealth) -- specific program/agency not named in document Medicaid FFS
Wisconsin Department of Health Services
—
—
3.1 · 1.0 d
151.2 · 67.2 h
expedited mean over 72 hours
mean and median three times apart
mean and median three times apart
Wyoming High Fidelity Wraparound CME Medicaid FFS
Magellan Healthcare
—
—
8.0 · 7.0 d
— · —
standard mean over 7 days
Health First Colorado / CHP+ (13 PA programs combined) Medicaid FFS
Colorado HCPF
—
—
5.6 · 1.5 d
26.4 · 10.3 h
mean and median three times apart
Virginia Medicaid Fee-for-Service (Cardinal Care FFS) Medicaid FFS
Virginia DMAS
—
—
5.2 · —
75.8 · —
expedited mean over 72 hours
Utah Medicaid Medicaid FFS
Utah DHHS
—
—
4.8 · 4.0 d
107.5 · 96.0 h
expedited mean over 72 hours
Calendar Year 2025 Prior Authorization Metrics (program not named in document) Medicaid FFS
Commonwealth of Massachusetts
—
—
4.2 · 2.0 d
32.0 · 2.0 h
mean and median three times apart
Med-QUEST aggregate (QUEST Integration plans plus FFS) Medicaid FFS
Hawaii Med-QUEST
—
—
4.2 · 1.0 d
17.3 · 7.0 h
mean and median three times apart
Wyoming Department of Health, Healthcare Finance, Home and Community Based Services Medicaid FFS
Wyoming Department of Health, Healthcare Finance, Home and Community Based Services
—
—
3.0 · 0.6 d
— · —
mean and median three times apart
Wyoming Department of Health, Healthcare Financing, Utilization Management Medicaid FFS
Wyoming Department of Health, Healthcare Financing, Utilization Management
—
—
3.0 · 0.6 d
0.0 · 0.0 h
mean and median three times apart
Connecticut Medicaid (HUSKY) FFS - Medical Medicaid FFS
Connecticut DSS
—
—
2.0 · 0.0 d
32.0 · 3.0 h
mean and median three times apart
02 · Who denies the most
Organizations, by denials issued
Standard denials summed across every filing the organization published that carries counts. The rate beside each is that organization's own volume-weighted rate.
Highest rates, organizations with 10,000+ requestsⓘ
Plans with the most denials
Plan
Market
State
Requests
Denied
Rate
Medi-Cal Dental Fee-for-ServiceCalifornia DHCS
Medicaid FFS
CA
3,138,788
926,119
29.5%
Health First Colorado / CHP+ (13 PA programs combined)Colorado HCPF
Medicaid FFS
CO
1,746,685
389,506
22.3%
California Children's Services (CCS)California DHCS
Medicaid FFS
CA
755,850
200,549
26.5%
Virginia Medicaid Fee-for-Service (Cardinal Care FFS)Virginia DMAS
Medicaid FFS
VA
724,465
177,032
24.4%
Medi-Cal Fee-for-Service (medical and behavioral health)California DHCS
Medicaid FFS
CA
78,987
22,404
28.4%
Medi-Cal and CHIP (fee-for-service)California Department of Health Care Services
Medicaid FFS
CA
78,987
22,404
28.4%
Connecticut Medicaid (HUSKY) FFS - MedicalConnecticut DSS
Medicaid FFS
CT
254,570
16,381
6.4%
Indiana Health Coverage Programs (fee-for-service)Indiana Family and Social Services Administration
Medicaid FFS
IN
204,568
10,442
5.1%
Alaska Medicaid (fee-for-service)Alaska Department of Health
Medicaid FFS
AK
430,236
9,019
2.1%
Wisconsin Medicaid (ForwardHealth) -- specific program/agency not named in documentWisconsin Department of Health Services
Medicaid FFS
WI
165,012
6,556
4.0%
Denial rate by stateⓘ
click a state for its filings≤ 2.8%2.8% – 4.8%4.8% – 5.2%5.2% – 22.3%> 22.3%not published
03 · Scale and scrutiny
Does a bigger plan say no more often?
Every filing with 100 or more standard requests: request volume across (log scale), denial rate up, coloured by market. A plan far above its neighbours of the same size and market is the one to read.
Denial rate against request volume, 21 filings click a point for the filing
1001K10K100K1M requests
● Medicaid FFS
Median rate by market and size bandⓘ
Highest for their sizeⓘ
Plan
Market · band
State
Requests
Band median
Rate
Medi-Cal Dental Fee-for-ServiceCalifornia DHCS
Medicaid FFS · 100K+
CA
3,138,788
6.4%
29.5% +23.1
California Children's Services (CCS)California DHCS
Medicaid FFS · 100K+
CA
755,850
6.4%
26.5% +20.1
Medi-Cal Fee-for-Service (medical and behavioral health)California DHCS
Medicaid FFS · 10K–100K
CA
78,987
10.3%
28.4% +18.0
Medi-Cal and CHIP (fee-for-service)California Department of Health Care Services
Medicaid FFS · 10K–100K
CA
78,987
10.3%
28.4% +18.0
Virginia Medicaid Fee-for-Service (Cardinal Care FFS)Virginia DMAS
Medicaid FFS · 100K+
VA
724,465
6.4%
24.4% +18.0
Health First Colorado / CHP+ (13 PA programs combined)Colorado HCPF
Medicaid FFS · 100K+
CO
1,746,685
6.4%
22.3% +15.9
Ohio Medicaid Fee-for-ServiceOhio Department of Medicaid
Medicaid FFS · 10K–100K
OH
30,872
10.3%
17.1% +6.8
Med-QUEST aggregate (QUEST Integration plans plus FFS)Hawaii Med-QUEST
Medicaid FFS · 100K+
HI
122,333
6.4%
8.3% +1.9
Connecticut Medicaid (HUSKY) FFS - MedicalConnecticut DSS
Medicaid FFS · 100K+
CT
254,570
6.4%
6.4% +0.0
Wyoming Medicaid Utilization Management (FFS)Wyoming Department of Health
Medicaid FFS · 10K–100K
WY
10,708
10.3%
10.3% +0.0
Wyoming Department of Health, Healthcare Financing, Utilization ManagementWyoming Department of Health, Healthcare Financing, Utilization Management
Medicaid FFS · 10K–100K
WY
10,708
10.3%
10.3% +0.0
Mississippi Medicaid Fee-for-ServiceMississippi Division of Medicaid
Medicaid FFS · 10K–100K
MS
60,252
10.3%
10.2% +-0.2
04 · The appeal gap
Most denials are never tested
Among filings that publish appeal counts (14 of them), 50.9% of standard denials were appealedⓘ, and 1.1% of those appeals overturned the denial. An overturn rate describes the denials someone fought; the denials nobody fought are the larger number, and it is listed here.
1.8M
standard denials in filings that report appeals the filings
909K
appeals filed · 50.9% of denials
1.1%
of appeals overturned the denial
875K
denials never appealedⓘ
Plan
Organization
Denied
Appeals
Appeal rate
Overturned
Never appealed
Medi-Cal Dental Fee-for-Service Medicaid FFS, CA
California DHCS
926,119
2,430
0.3%
66.8%
923,689
California Children's Services (CCS) Medicaid FFS, CA
California DHCS
200,549
15
0.0%
6.7%
200,534
Virginia Medicaid Fee-for-Service (Cardinal Care FFS) Medicaid FFS, VA
Virginia DMAS
177,032
11,298
6.4%
8.6%
165,734
Medi-Cal Fee-for-Service (medical and behavioral health) Medicaid FFS, CA
California DHCS
22,404
43
0.2%
7.0%
22,361
Medi-Cal and CHIP (fee-for-service) Medicaid FFS, CA
California Department of Health Care Services
22,404
43
0.2%
7.0%
22,361
Connecticut Medicaid (HUSKY) FFS - Medical Medicaid FFS, CT
Connecticut DSS
16,381
2,362
14.4%
38.4%
14,019
Indiana Health Coverage Programs (fee-for-service) Medicaid FFS, IN
Indiana Family and Social Services Administration
10,442
583
5.6%
27.8%
9,859
Alaska Medicaid (fee-for-service) Medicaid FFS, AK
Alaska Department of Health
9,019
34
0.4%
38.2%
8,985
Mississippi Medicaid Fee-for-Service Medicaid FFS, MS
Mississippi Division of Medicaid
6,119
991
16.2%
72.7%
5,128
Wyoming Medicaid Utilization Management (FFS) Medicaid FFS, WY
Wyoming Department of Health
1,106
20
1.8%
25.0%
1,086
Wyoming Department of Health, Healthcare Financing, Utilization Management Medicaid FFS, WY
Wyoming Department of Health, Healthcare Financing, Utilization Management
1,106
20
1.8%
25.0%
1,086
Connecticut Medicaid (HUSKY) FFS - Behavioral Health Medicaid FFS, CT
Connecticut DSS
876
297
33.9%
61.3%
579
Michigan Medicaid Home and Community Based Services (Aging and Community Services Division, incl. Brain Injury Services and Community Transition Services) - Fee-for-Service Medicaid FFS, MI
Michigan Department of Health and Human Services
175
0
0.0%
—
175
Health First Colorado / CHP+ (13 PA programs combined) Medicaid FFS, CO
Colorado HCPF
389,506
890,401
228.6%
0.6%
-500,895
Everything on this page is computed from the published counts in the filings; the plan pages show the source document for each figure. Where a plan published a rate without counts it cannot appear here, because a rate nobody can check is not a number of denials.