Prior Authorization Reporting
Prior authorization
Some medical services and treatments need to be approved by your health plan as "medically necessary" before you can get them. Your primary care provider (PCP) or other health care provider must get approval from your health plan — this is called “prior authorization.” This process helps make sure you get the care you need, as well as helping to stop fraud, waste, and abuse.
Centers for Medicare & Medicaid Services (CMS) requirement
Every year, AmeriHealth Caritas Delaware must provide data on our website about how many prior authorizations were submitted and approved or denied. The report must be posted by March 31. This reporting is part of CMS Interoperability and Prior Authorization Final Rule CMS-0057-F.
AmeriHealth Caritas Delaware 2025 Prior Authorization Report
AmeriHealth Caritas Delaware — Medicaid
| Number of requests | Percentage |
|---|---|---|
Standard (non-urgent) prior authorization (PA) requests | ||
Total PA requests received: | 70,575 | 100% |
Finalized PAs | ||
Approved: | 50,588 | 71.7% |
Denied: | 19,987 | 28.3% |
Other: | 0 | 0% |
Appeals | ||
Total PAs appealed: | 1,276 |
|
PAs approved after appeal: | 305 | 0.4% |
PAs denied after appeal: | 971 | 1.4% |
PAs pending appeal: | 0 | 0% |
Expediated (urgent) PA requests | ||
Total PA requests received: | 6,971 | 100% |
Finalized PAs | ||
Approved: | 6,110 | 87.6% |
Denied: | 861 | 12.4% |
Other: | 0 | 0% |
Appeals | ||
Total PAs appealed: | 92 |
|
PAs approved after appeal: | 82 | 1.2% |
PAs denied after appeal: | 10 | 0.1% |
PAs pending appeal: | 0 | 0% |
Time between receiving a PA request and sending a decision
Mean (average) time | Median (middle) time | |
|---|---|---|
Standard (non-urgent) PA requests | 3.4 days | 3 days |
Expedited (urgent) PA requests | 35.6 hours | 22 hours |
AmeriHealth Caritas Delaware — CHIP
| Number of requests | Percentage |
|---|---|---|
Standard (non-urgent) prior authorization (PA) requests | ||
Total PA requests received: | 2,764 | 100% |
Finalized PAs | ||
Approved: | 1,426 | 51.6% |
Denied: | 1,338 | 48.4% |
Other: | 0 | 0% |
Appeals | ||
Total PAs appealed: | 123 |
|
PAs approved after appeal: | 14 | 0.5% |
PAs denied after appeal: | 109 | 3.9% |
PAs pending appeal: | 0 | 0% |
Expediated (urgent) PA requests | ||
Total PA requests received: | 35 | 100% |
Finalized PAs | ||
Approved: | 24 | 68.6% |
Denied: | 11 | 31.4% |
Other: | 0 | 0% |
Appeals | ||
Total PAs appealed: | 0 |
|
PAs approved after appeal: | 0 | 0% |
PAs denied after appeal: | 0 | 0% |
PAs pending appeal: | 0 | 0% |
Time between receiving a PA request and sending a decision
Mean (average) time | Median (middle) time | |
|---|---|---|
Standard (non-urgent) PA requests | 4 days | 2 days |
Expedited (urgent) PA requests | 36.3 hours | 31 hours |