CMS Prior Authorization Reporting - Qualified Health Plans

To comply with the CMS Interoperability and Prior Authorization final rule, Louisiana Blue is required to annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year. Publicly reporting these metrics promotes transparency and accountability, helps patients understand prior authorization processes, and enables providers to evaluate payer performance. In addition, metrics can be used to compare plans, programs, and payers.

Below are the CMS required metrics for the Louisiana Blue QHP Plans for reporting year 2025:

01/01/2025-12/31/2025 LHSIC HMO
The number of standard (non-urgent) prior authorization requests received 10,856 62,789
The number of standard (non-urgent) prior authorization requests approved 10,158 58,722
The percentage of standard (non-urgent) prior authorization requests that were approved 93.57% 93.52%
The number of standard (non-urgent) prior authorization requests denied 698 4,067
The percentage of standard (non-urgent) prior authorization requests that were denied 6.43% 6.48%
The number of standard (non-urgent) prior authorization requests for which the timeframe for review was extended and the request was approved Not applicable Not applicable
The percentage of standard (non-urgent) prior authorization requests for which the timeframe for review was extended and the request was approved Not applicable Not applicable
The number of appeals received on standard (non-urgent) prior authorization requests 87 394
The number of standard (non-urgent) prior authorization requests that were approved after appeal 25 143
The percentage of standard (non-urgent) prior authorization requests that were approved after appeal 29% 36%
The number of expedited (urgent) prior authorization requests received 1,002 4,209
The number of expedited (urgent) prior authorization requests approved 962 4,055
The percentage of expedited (urgent) prior authorization requests that were approved. 96.01% 96.34%
The number of expedited (urgent) prior authorization requests that were denied 40 154
The percentage of expedited (urgent) prior authorization requests that were denied. 3.99% 3.66%
The number of expedited (urgent) prior authorization requests for which the timeframe for review was extended Not applicable Not applicable
The percentage of expedited (urgent) prior authorization requests for which the timeframe for review was extended and the request was approved Not applicable Not applicable
The average time that elapsed between the submission of a prior authorization request and a determination for standard (non-urgent) prior authorizations* < 1 day < 1 day
The median time that elapsed between the submission of a prior authorization request and a determination for standard (non-urgent) prior authorizations 0 days** 0 days**
The average time that elapsed between the submission of a prior authorization request and a determination for expedited (urgent) prior authorizations* 18 hours 17 hours
The median time that elapsed between the submission of a prior authorization request and a determination for expedited (urgent) prior authorizations. 5 hours 4 hours
*45 CFR 147.136(b)(3) QHP Plans must follow the ACA requirement for standard and expedited prior authorization timeframes of 15 days for standard requests and 72 hours for expedited (urgent) requests
**The median time for standard prior authorizations is 0 days because of the Louisiana Blue auto-approval rate for prior authorization requests

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