Prior Authorization for Medical Items and Services (Excluding Drugs)
To comply with the CMS Interoperability and Prior Authorization final rule, Medicare Advantage payers are required to annually report prior authorization metrics on our website. Publicly reporting this information promotes transparency and accountability to patients and providers.
To see the list of medical items and services for which Alignment Health requires prior authorization (excluding drugs), refer to the Alignment Healthcare Prior Authorization List.
If you have questions regarding the prior authorization list for a delegated entity, please contact our Delegation Oversight team at [email protected].
2025 Prior Authorization Metrics for Medical Items and Services (Excluding Drugs)
Standard (Non-Urgent) Prior Authorization Requests
|
Contract ID
|
Outcome
|
How Many Times This Happened
|
Out of Total Requests
|
Percentage
|
|
H3443
|
Request Approved
|
13,448
|
14,282
|
94.16%
|
|
H3443
|
Request Denied
|
834
|
14,282
|
5.84%
|
|
H3815
|
Request Approved
|
819,796
|
837,729
|
97.86%
|
|
H3815
|
Request Denied
|
17,933
|
837,729
|
2.14%
|
|
H4961
|
Request Approved
|
4,917
|
5,063
|
97.12%
|
|
H4961
|
Request Denied
|
146
|
5,063
|
2.88%
|
|
H5296
|
Request Approved
|
42,068
|
43,675
|
96.32%
|
|
H5296
|
Request Denied
|
1,607
|
43,675
|
3.68%
|
|
H5472
|
Request Approved
|
8,977
|
9,318
|
96.34%
|
|
H5472
|
Request Denied
|
341
|
9,318
|
3.66%
|
|
H7074
|
Request Approved
|
372
|
380
|
97.89%
|
|
H7074
|
Request Denied
|
8
|
380
|
2.11%
|
|
H8832
|
Request Approved
|
3,927
|
4,044
|
97.11%
|
|
H8832
|
Request Denied
|
117
|
4,044
|
2.89%
|
Standard (Non-Urgent) Requests Approved After Timeframe for Review Was Extended
|
Contract ID
|
How Many Times This Happened
|
Out of Total Requests
|
Percentage
|
|
H3443
|
0
|
0
|
0%
|
|
H3815
|
131
|
168
|
78%
|
|
H4961
|
0
|
0
|
0%
|
|
H5296
|
0
|
0
|
0%
|
|
H5472
|
0
|
0
|
0%
|
|
H7074
|
0
|
0
|
0%
|
|
H8832
|
0
|
0
|
0%
|
Standard (Non-Urgent) and Expedited (Urgent) Requests Approved After Appeal
|
Contract ID
|
How Many Times This Happened
|
Out of Total Appeals
|
Percentage
|
|
H3443
|
32
|
43
|
74%
|
|
H3815
|
411
|
737
|
56%
|
|
H4961
|
8
|
13
|
62%
|
|
H5296
|
87
|
129
|
67%
|
|
H5472
|
22
|
37
|
59%
|
|
H7074
|
1
|
1
|
100%
|
|
H8832
|
9
|
12
|
75%
|
Expedited (Urgent) Prior Authorization Requests
|
Contract ID
|
Outcome
|
How Many Times This Happened
|
Out of Total Requests
|
Percentage
|
|
H3443
|
Request Approved
|
4,061
|
4,204
|
96.60%
|
|
H3443
|
Request Denied
|
143
|
4,204
|
3.40%
|
|
H3815
|
Request Approved
|
128,108
|
131,895
|
97.13%
|
|
H3815
|
Request Denied
|
3,787
|
131,895
|
2.87%
|
|
H4961
|
Request Approved
|
1,604
|
1,636
|
98.04%
|
|
H4961
|
Request Denied
|
32
|
1,636
|
1.96%
|
|
H5296
|
Request Approved
|
11,781
|
12,105
|
97.32%
|
|
H5296
|
Request Denied
|
324
|
12,105
|
2.68%
|
|
H5472
|
Request Approved
|
4,417
|
4,537
|
97.36%
|
|
H5472
|
Request Denied
|
120
|
4,537
|
2.64%
|
|
H7074
|
Request Approved
|
98
|
99
|
98.99%
|
|
H7074
|
Request Denied
|
1
|
99
|
1.01%
|
|
H8832
|
Request Approved
|
1,567
|
1,601
|
97.88%
|
|
H8832
|
Request Denied
|
34
|
1,601
|
2.12%
|
Expedited (Urgent) Requests Approved After Timeframe for Review Was Extended
|
Contract ID
|
How Many Times This Happened
|
Out of Total Requests
|
Percentage
|
|
H3443
|
0
|
0
|
0%
|
|
H3815
|
32
|
45
|
71%
|
|
H4961
|
0
|
0
|
0%
|
|
H5296
|
0
|
0
|
0%
|
|
H5472
|
0
|
0
|
0%
|
|
H7074
|
0
|
0
|
0%
|
|
H8832
|
0
|
0
|
0%
|
Time Between Receiving a Prior Authorization Request and Sending a Decision
|
Contract ID
|
Auth Request Type
|
Mean (Average) Time in Days
|
Median (Middle) Time in Days
|
|
H3443
|
Standard (non-urgent)
|
2.15
|
1.00
|
|
H3443
|
Expedited (urgent)
|
0.79
|
0.59
|
|
H3815
|
Standard (non-urgent)
|
1.90
|
0.50
|
|
H3815
|
Expedited (urgent)
|
0.86
|
0.62
|
|
H4961
|
Standard (non-urgent)
|
3.06
|
3.00
|
|
H4961
|
Expedited (urgent)
|
1.00
|
0.62
|
|
H5296
|
Standard (non-urgent)
|
2.78
|
2.50
|
|
H5296
|
Expedited (urgent)
|
0.79
|
0.58
|
|
H5472
|
Standard (non-urgent)
|
2.27
|
1.00
|
|
H5472
|
Expedited (urgent)
|
0.69
|
0.53
|
|
H7074
|
Standard (non-urgent)
|
0.04
|
0.00
|
|
H7074
|
Expedited (urgent)
|
0.02
|
0.00
|
|
H8832
|
Standard (non-urgent)
|
1.86
|
0.75
|
|
H8832
|
Expedited (urgent)
|
0.89
|
0.57
|
“0” means the request was processed same day.