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
Behavioral Health (Lucet) 1,327 1,320 7 99% 819 - - -
Inpatient Behavioral Health 1,023 989 34 97% 959 2 1 1
Inpatient Medical 3,047 2,955 92 97% 1,620 41 17 24
Outpatient Behavioral Health 3,917 3,590 327 92% 3,829 12 10 2
Outpatient Medical 78,334 63,677 14,657 81% 77,638 297 133 164
Prescription Drug (BPI) 91 41 50 45% 16 - - -
Prescription Drug (Magellan) 7.235 6,433 802 89% 6,693 6 3 10
Vision (Davis Vision) 34 29 5 85% - 1 1 -
                 


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 6,563 6,560 3 100% 6,553 - - -
Inpatient Medical 5,405 4,011 1,394 74% 5,403 9 3 6
Outpatient Behavioral Health 2,786 2,737 49 98% 2,782 11 6 5
Outpatient Medical 154,326 141,930 12,396 92% 154,298 424 129 295
Prescription Drug (Magellan) 6,888 6,734 154 98% 6,888 - - -
                 


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.